Failure to Properly Secure Wheelchair During Van Transport Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to properly secure a resident’s wheelchair in the facility van, resulting in a fall during transport. The facility’s accident/incident policy stated that all persons involved in an incident or accident, or suspected to have had one, are to be evaluated, treated as indicated, and monitored. For one resident who depended on a wheelchair for mobility, the incident report documented that while en route to a medical appointment, the resident fell backwards in the wheelchair and hit the back of the head, causing a small hematoma. The facility’s investigation concluded that although the resident was strapped in, the transportation assistant failed to ensure that the wheelchair straps were appropriately placed to firmly secure the chair, which allowed the chair to roll backwards. The QAPI committee’s review identified the primary cause of the fall as the resident’s wheelchair not being properly secured with appropriate straps to maintain a stable and secure position during transportation. CNA #1 reported that she used four hooks to secure the wheelchair frame to the van’s securement system and that the wheelchair was attached to the floor. During transport, she heard a noise, looked back, and saw the resident on the van floor with the wheelchair turned on its side and the seatbelt no longer secured around the resident. CNA #1 stated that the resident reported hitting her head and having head pain. CNA #2, who was driving, similarly reported hearing a noise, then observing the resident on the floor with the wheelchair on its side, and confirmed that no checklist was used to verify correct securement of the wheelchair. The Administrator stated she was notified shortly after the incident that the resident’s wheelchair had fallen over in the van and that the resident had hit her head and complained of head pain. The Maintenance Supervisor later inspected the van’s resident securement system and found all components intact and functioning correctly, indicating that the issue was not equipment failure but how the securement system was used. The resident’s records showed admission with diagnoses including COPD, heart failure, and rheumatoid arthritis, and a significant change MDS with a BIMS score of 9, indicating moderate cognitive impairment, and a need for a wheelchair for mobility. The hospital After Visit Summary documented that the resident was evaluated in the emergency department for a fall and head injury, with imaging showing no new diagnoses, and treatment with an over-the-counter analgesic.
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