Failure to Properly Secure Resident During Transport Results in Injury
Penalty
Summary
A deficiency occurred when a facility failed to ensure the safety of a resident during transport by not properly securing the resident in a wheelchair-accessible van and failing to maintain a safe speed. The resident, who had a history of generalized weakness, was at risk for falls and was dependent on hemodialysis. The care plan for this resident included interventions for fall risk and anticoagulant therapy, but these were not effectively implemented during the transport event. During the incident, the van driver accelerated onto an expressway, causing the unsecured resident to tip back in her wheelchair and strike her head, shoulders, and knees against the van lift rails. Documentation and interviews revealed that the driver did not properly use the required straps and seat belt to secure the resident and wheelchair, as outlined in facility policy and training. The driver admitted uncertainty about the use of the straps and acknowledged that the resident was not strapped down properly at the time of the incident. As a result of the incident, the resident sustained a scalp hematoma, pain in both shoulders and knees, and was later found to have a fractured vertebra. The facility's investigation confirmed that all van equipment was functioning properly and that the driver had previously received safety training. Staff interviews corroborated that the driver failed to follow established procedures for securing residents during transport, directly leading to the resident's injuries.