Failure to Secure Resident With Seat Belt During Wheelchair Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate accident-prevention interventions during transport for one cognitively intact resident. The resident was admitted with multiple diagnoses including left knee pain, diverticulosis, bone density disorder, epilepsy, hyperlipidemia, hypertension, type 2 diabetes, weakness, difficulty walking, lack of coordination, and a sacral fracture. The resident was later discharged from the facility following an incident that occurred while being transported back from an outside appointment. Upon readmission, the resident had new diagnoses of distal femur fracture, fibula fracture, and bimalleolar ankle fracture. According to the facility’s investigation and staff interview, the facility driver placed the resident in the facility van and anchored the wheelchair to the floor using the appropriate strap devices but did not ensure that the van seat belt was applied to the resident. While returning to the facility, the driver encountered backed-up traffic around a corner with a significant blind spot and had to brake hard. As a result, the resident came out of the wheelchair and landed on the van floor. The driver then pulled into a business parking lot, assessed the resident, contacted the facility, and was directed to call 911, after which the resident was transported to a hospital. The driver later stated he thought the seat belt had been applied but had apparently forgotten to do so.
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