Failure to Properly Secure Resident During Transport Results in Injury
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including congestive heart failure, diabetes, and a history of falls, was not properly secured during transport in the facility's van. The resident, who was cognitively intact but required extensive assistance for mobility and used an electric wheelchair, was being transported to an outside appointment. During the trip, the van driver had to make a sudden stop, causing the resident's wheelchair to tip forward and the resident to fall, resulting in injury. The incident led to the resident being admitted to the hospital for pain control and monitoring after sustaining a head injury and significant back pain. The investigation revealed that the resident's wheelchair was equipped with a positioning belt, which is not designed for use as a seatbelt in a motor vehicle. The facility's transport van was equipped with a four-point wheelchair securement system (Q'Straint) and a shoulder and pelvic belt restraint, which are required to be used together for safe transport. However, the driver only used the wheelchair's positioning belt and did not secure the resident with the van's shoulder belt. There was also uncertainty about whether the wheelchair was properly attached to the van floor at the time of the incident, as conflicting accounts were given by staff and the resident. Further review found that the facility did not have a formal training policy or documentation for staff responsible for operating the van and its securement systems. Training was informal and undocumented, with no checklists or records of topics covered. The lack of proper use of the securement system and inadequate staff training directly contributed to the resident's injury during transport.