Failure to Prevent Accident Hazard During Wheelchair Transport
Penalty
Summary
A deficiency occurred when a resident, who had a history of stroke with right-sided weakness and morbid obesity, was transported in a wheelchair while sitting on multiple items, including a dycem, cushion, and bath blanket. The wheelchair was not equipped with only manufacturer-approved cushioning, and these additional items were not removed prior to transport. During the van ride, the driver applied the brakes suddenly to avoid a deer, causing the resident to slide under the safety belts and fall onto the wheelchair foot pedals. The resident's right foot became pinned between the wheelchair wheel and the seat belt device on the van floor, resulting in a right ankle fracture that required hospital treatment. Observation, interview, and record review confirmed that the environment was not free from accident hazards, as the use of multiple non-standard items in the wheelchair contributed to the resident's fall and injury. The CNA accompanying the resident and the van driver were unable to assist the resident after the fall, necessitating emergency services to extricate and transport the resident to the hospital. The Director of Nursing acknowledged that the presence of multiple items in the wheelchair could have contributed to the hazard.