Failure to Properly Secure Wheelchair During Transport Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident's wheelchair was not properly secured during transport in the facility's wheelchair van, resulting in the wheelchair tipping over while the van was in motion. The incident involved two CNAs who were splitting transportation duties. One CNA was responsible for loading the resident into the van and securing the wheelchair, while the other CNA was responsible for driving the resident to her appointment. The CNA who loaded the resident into the van secured only the back two straps of the wheelchair and fastened the resident's seatbelt, but failed to secure the front two straps. The CNA intended to secure the front straps from the side doors but forgot to do so before handing off the transport to the other CNA. The CNA who drove the van did not verify that the wheelchair was fully secured before departing. The resident involved had multiple significant medical diagnoses, including chronic respiratory failure with hypoxia, COPD with exacerbation, centrilobular emphysema, paroxysmal atrial fibrillation, hypertension, dysphagia, malignant neoplasms, acquired absence of the right leg above the knee, peripheral vascular disease, chronic pain, and hyperlipidemia. The resident was cognitively intact and required moderate assistance for sitting, standing, and transfers. During the transport, as the van was making a left turn onto a highway ramp, the resident's wheelchair tipped backward, causing her to hit her head on the wheelchair ramp. Emergency services were called, and the resident was transported to the hospital for evaluation. She was diagnosed with a closed head injury and sustained abrasions to her chin, right cheek, and right neck, but imaging showed no acute traumatic pathology. Interviews with the involved staff confirmed that there was a miscommunication and lack of verification regarding the proper securing of the wheelchair. The CNA who loaded the resident admitted to forgetting to secure the front straps, and the CNA who drove the van did not check the straps before departure. The resident reported feeling scared during the incident and experienced pain in her neck and shoulders following the event. The facility's investigation substantiated the allegation of neglect related to the failure to ensure the resident's wheelchair was properly secured during transport.