Failure to Properly Secure Wheelchair Residents During Transportation
Penalty
Summary
Staff failed to ensure a safe environment free from accident hazards during resident transportation when a van driver transported two wheelchair-bound residents in a facility medical van that was only equipped with six straps, despite facility policy requiring eight straps to safely secure two wheelchairs. The van driver made the decision to transport both residents at the same time to prevent them from being late for their appointments, and while driving, one resident's wheelchair flipped backward after a turn, resulting in the resident falling. The van driver stopped, checked on the resident, repositioned them, and returned to the facility. The resident involved had a history of spinal stenosis, anxiety, depression, and required total assistance for transfers, with a documented risk for falls. After the incident, the resident complained of head and neck pain and was transported to the hospital, where a closed head injury was diagnosed. The facility's Executive Director was unaware of the van's strap limitations prior to the incident. The facility's Fleet Safety Program policy required proper securing of residents during transport, but this was not followed, leading to the accident.