Resident Injury Due to Improper Wheelchair Securement During Transport
Penalty
Summary
A deficiency occurred when a resident with multiple risk factors, including dementia, osteoporosis, muscle weakness, difficulty walking, and a history of falls, was injured during transportation to a medical appointment. The resident, who required substantial to maximal assistance with mobility and used a wheelchair, was being transported in a facility vehicle operated by an activities assistant. During the trip, the driver had to make a sudden, hard stop to avoid an accident, which resulted in the resident's seatbelt becoming unfastened and the resident falling out of the wheelchair. Investigation revealed that the seatbelt used to secure the resident was not properly latched due to the use of non-compatible seatbelt components from different manufacturers. The driver believed the seatbelt was secure, but under force, it came loose, allowing the resident to be ejected from the wheelchair. The wheelchair itself was locked in place, but the improper securement of the seatbelt failed to protect the resident during the abrupt stop. As a result of the fall, the resident sustained a left femur fracture with intercondylar extension, skin tears, and required surgical intervention. The incident was confirmed through interviews, record reviews, and observations, which established that the facility failed to ensure the resident was free from accident hazards and did not provide adequate supervision or equipment compatibility to prevent the accident during transportation.