Unsecured Wheelchair Transport Leads to Resident Injury in Facility Van
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly secured with a seatbelt while being transported in the facility’s van, resulting in the resident falling from the wheelchair onto the floor of the moving vehicle. The resident had multiple significant medical conditions, including a prior cerebral infarction with right-sided flaccid hemiplegia and hemiparesis, obesity, COPD, osteoporosis, osteoarthritis of both knees, dependence on a wheelchair, and long-term anticoagulant use. The resident’s MDS showed intact cognition with a BIMS score of 15 and documented dependence or substantial/maximal assistance for most ADLs, including transfers and mobility-related tasks. The care plan identified the resident as at risk for falls due to weakness and at greater risk of injury and fractures due to osteoporosis, and documented that the wheelchair was the primary mode of transport and that the resident required extensive assistance with transfers, including use of a sit-to-stand lift for all transfers as of the most recent updates. On the day of the incident, the resident was being transported back to the facility from a physician’s appointment in a facility transport van, seated in a wheelchair on a metal floor equipped with straps for wheelchair securement. Activity staff driving the van did not apply a seatbelt to secure the resident before driving, contrary to the facility’s written policy that all elders and passengers, including the driver, will wear a seatbelt at all times when the vehicle is in motion, without exception. As the van traveled on a highway and crested a hill, the driver encountered a stopped school bus in the opposite lane and multiple stopped cars in the same lane ahead, requiring the driver to apply the brakes quickly. Because the resident was not secured with a seatbelt, the sudden braking caused the resident to slide forward out of the wheelchair and fall onto the floor of the van behind the front seats. Following the fall, the resident remained on the floor of the van while the driver continued driving approximately a mile and a half back to the facility, stating there was no shoulder to pull over and that the resident could not be returned to the wheelchair. The resident later reported that she had not been wearing a seatbelt, that both she and the driver had forgotten to apply it, and that this had never happened before. Upon arrival at the facility, nursing staff found the resident lying on her back in the van, alert and oriented, with a small abrasion on the forehead, a bleeding skin tear on the left lower leg, and significant pain in the right upper extremity with movement. EMS was called, and the resident was transported to the hospital, where ED documentation confirmed a proximal right humerus fracture, a large skin tear of the lower leg, and a forehead contusion. The surveyors determined that the failure to secure the resident with a seatbelt in the transport van, in violation of facility policy and despite the resident’s known fall and fracture risk, resulted in injuries and constituted immediate jeopardy.
Removal Plan
- Suspended Activity Staff Z pending investigation
- Provided education regarding transportation safety to the facility’s only other driver
- Placed signs in the transport vehicles as visual reminders for residents and drivers to use seat belts
- Removed Activity Staff Z from driving duties
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