Wheelchair Not Properly Secured During Van Transport Leading to Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s wheelchair was properly secured during transport in the facility’s van, resulting in the wheelchair tipping over. The resident involved had multiple medical diagnoses, including Type 2 diabetes mellitus, end stage renal disease, peripheral vascular disease, lumbar intervertebral disc degeneration, prior L1 vertebral fracture, low back pain, essential tremor, and a left below-knee amputation. The resident was cognitively intact, used a manual wheelchair for locomotion, did not ambulate, and was assessed as a high fall risk with care plans identifying risk for falls related to her diagnoses and medications. On the day of the incident, the resident was transported to an appointment in the facility’s small van. Upon returning, her wheelchair tipped backwards in the van while she was strapped in with the wheelchair brakes engaged. The resident reported that she was strapped in properly and that the driver did not accelerate or brake abruptly when the wheelchair tipped. Staff interviews confirmed that the resident’s wheelchair brakes were locked and that she was secured in the van at the time of the incident. The Maintenance Director and the transport CNA indicated that the van’s wheelchair securement system uses straps with a red lever that, if pressed or contacted (for example, by a resident’s foot), could loosen the straps securing the wheelchair. After the wheelchair tipped, the resident hit the back of her head and upper back on the floor of the van. Nursing documentation and staff interviews describe a small hematoma to the back of the resident’s head, complaints of headache and lower back pain, and the resident’s refusal of immediate hospital evaluation and x‑rays. The facility initiated in‑house assessment and monitoring, and subsequent imaging, including a CT scan of the lumbar spine, later documented an acute L1 compression fracture along with degenerative disc disease and facet arthrosis. The facility’s transportation policy states that it is the facility’s responsibility to ensure any resident transported by facility vehicle has a safe and secure transport, which was not achieved in this incident when the wheelchair tipped while the resident was secured in the van.
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