Unsafe Wheelchair Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of chronic lymphocytic leukemia, traumatic subdural hemorrhage, and spondylolysis was not safely transferred onto a facility transportation van. The resident, who was dependent on staff for transfers and locomotion in a manual wheelchair, was being transported to a dental appointment accompanied by his daughter. During the transfer, the transportation driver attempted to push the resident in his wheelchair up the van's side entry ramp facing forward, but the wheelchair's footrests and metal bars prevented entry. The driver then removed the leg rests and attempted to pull the resident backward up the ramp, resulting in the resident falling forward out of the wheelchair onto the concrete ground. The fall resulted in the resident sustaining multiple injuries, including skin tears and abrasions to the head, left elbow, and fingers on both hands, as well as complaints of back pain. The resident was alert and oriented after the fall but required immediate first aid and was subsequently transferred to the hospital by EMS. Hospital evaluation confirmed an acute re-bleed of a chronic subdural hematoma, along with superficial injuries and a negative right shoulder x-ray. The incident was witnessed by the resident's daughter and corroborated by multiple staff statements, which described the sequence of events and the resident's condition following the fall. The investigation revealed that the transportation driver did not follow safe wheelchair transport procedures, specifically by attempting to pull the resident backward up an inclined ramp, which led to the resident falling forward. The care plan for the resident included interventions to maintain safety, such as keeping the environment free from clutter and ensuring staff assistance for transfers, but these were not adequately implemented during the transfer to the van. The incident resulted in actual harm to the resident, including hospitalization and further medical evaluation.