Failure to Secure Wheelchair During Van Loading Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to properly secure a resident's wheelchair during the process of loading the resident onto a facility van lift platform. The facility's policy required that both wheelchair brakes be locked before operating the lift, but the CNA only locked one wheel. As a result, the wheelchair rolled backward off the lift platform while the resident was seated, causing the resident to fall onto the concrete driveway. The resident involved had a history of hemiplegia affecting the right dominant side and was non-ambulatory, requiring a wheelchair for mobility. At the time of the incident, the resident was returning from a dialysis appointment and was cognitively intact. The fall resulted in the resident sustaining a scapular fracture and multiple rib fractures, as confirmed by hospital imaging. The resident reported pain and was later transported to an acute care hospital for further evaluation and treatment. Interviews with facility staff and the resident confirmed that the CNA did not follow the required safety procedures for securing the wheelchair. The CNA admitted to failing to lock both wheels, and staff interviews corroborated that the incident occurred while the lift was on the ground. The facility's investigation concluded that the CNA's failure to adhere to established protocols directly led to the resident's fall and subsequent injuries.