Failure to Properly Secure Wheelchair During Van Transport Resulting in Multi-System Trauma
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during wheelchair van transportation, resulting in multi-system trauma and transfer to a trauma center. Facility policy on abuse and neglect required a safe and secure environment and protection from neglect, and the transportation policy required all drivers to be competent in Q-Straint wheelchair securement, van lift operation, driver responsibilities while escorting a resident, and safe vehicle operation. The Q-Straint system in use was described as a five-point system, with four points connecting to the wheelchair and a chest lap harness as the fifth point. The resident involved, identified as cognitively intact with a BIMS score of 15, had diagnoses including atrial fibrillation, heart failure, and hypertension, and was receiving Lovenox. On the day of the incident, the resident was being transported by wheelchair van to an appointment when, according to the resident’s statement, the van was taking a left-hand turn and the wheelchair tipped over, causing the resident to land on the right side and strike their head on the van door. The resident reported significant pain to the right shoulder and right hip, and was noted to have a small hematoma above the right ear and on the right ear; pain prevented full assessment of the right hip and shoulder while in bed. Hospital documentation indicated the resident stated they were not secure in the chair, although the chair itself was secured in the van, and that the wheelchair tipped and collapsed on the resident while going around a bend. The resident complained of right shoulder and hip pain and reported striking the side of the van and their head. Imaging revealed multiple injuries, including non-displaced fractures of C7 and T2 transverse processes, fractures of the first through fourth right ribs, a right clavicle fracture with possible joint extension, a non-displaced fracture of the posterior inferior right pubic ramus, an acute comminuted fracture of the anterior right hip acetabulum, and a questionable fracture of the right lateral sacrum. Facility documentation identified the incident as a fall with injury during wheelchair van transport due to failure to apply the passenger seatbelt, and both the resident and the maintenance manager reported that the chest lap harness (fifth point of the Q-Straint system) had not been applied, despite the driver having documented training on the Q-Straint securement system.
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