Resident Injury Due to Incomplete Wheelchair Securement During Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safe transport, resulting in a resident not being fully secured in a facility van and sustaining a closed head injury. One resident, admitted with diagnoses including UTI, acute respiratory failure with hypoxia, CKD, HTN, diastolic heart failure, and anxiety, was being transported to an appointment when her wheelchair was not properly secured in the transport van. The back straps of the wheelchair were attached, but the front straps were not secured, allowing the wheelchair to tip backward during transport. During the incident, the transport driver reported that the resident’s wheelchair tipped backward to about a 45-degree angle, and the resident struck her head on the back door or ramp of the van. The driver asked the resident if she was okay, and when she responded yes, he repositioned the wheelchair upright and then secured all four straps before continuing to the scheduled appointment. The driver did not contact emergency medical services at the time of the incident and proceeded with the transport after securing the wheelchair. Subsequently, the resident was evaluated at an urgent care clinic for a head injury that occurred earlier that day. The urgent care documentation indicated that the resident reported her wheelchair had not been secured, rolled back, and caused her to strike her head on the back door of the vehicle. She denied loss of consciousness, pain, headache, neck pain, or back pain at the time of evaluation, but was diagnosed with a closed head injury. Review of the resident’s medical record showed no documentation of the incident itself, although neurological checks were completed afterward. Interviews with the Transportation Director, the transport driver, and the Administrator confirmed that the resident had been transported in a van without built-in front retention straps and that the front straps had been forgotten, leading to the tipping event and resulting injury.
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