Failure to Secure Wheelchair Passenger Seatbelt During Van Transport Resulting in Multi-System Trauma
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents during wheelchair van transport, resulting in actual harm to a resident. Facility policies on Resident Accidents/Incidents and Reporting a Resident Incident During Transport required a safe and secure environment and cautious vehicle operation with resident safety as a priority. The resident involved had diagnoses including atrial fibrillation, heart failure, and hypertension, was cognitively intact with a BIMS score of 15, and was receiving Lovenox. While being transported to an appointment in the facility’s wheelchair van, the resident reported that the van was making a left-hand turn when the wheelchair tipped over, causing the resident to land on their right side and strike their head on the van door. The resident complained of significant right shoulder and hip pain and had hematomas above and on the right ear. Hospital documentation indicated the resident stated they were not secure in the wheelchair, although the wheelchair itself was secured to the van. Facility documentation of the incident identified that the fall with injury during wheelchair van transport occurred due to failure to apply the passenger seatbelt. The resident’s signed witness statement specified that the driver did not fasten the chest lap harness, and the resident reiterated in interview that while the wheelchair was strapped to the floor, the chest lap harness was never applied, allowing the chair to tip when the van went around a bend. The Maintenance Manager described the Q-Straint system as a five-point system, including a chest lap harness as the fifth point, and confirmed that all parts and belts were intact and functioning when examined the following day. The Nursing Home Administrator acknowledged that the facility failed to ensure adequate supervision and assistance to prevent accidents, which resulted in multi-system trauma and transfer to a trauma center hospital.
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