Resident Injury from Improper Securement During Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was safely secured during transport in the facility van, resulting in the resident falling from his wheelchair when the van made a sudden stop. The resident had a history of myocardial infarction, heart failure, hypertension, atrial fibrillation, COPD, and required oxygen, and his care plan documented limited physical mobility and the need for a wheelchair for ambulation. Despite being cognitively intact per the MDS, he was dependent on staff to properly secure his wheelchair and seat belt during transport. On the day of the incident, the van driver reported that a deer ran in front of the van, requiring abrupt braking, after which the resident was found on the floor of the van. Facility documentation initially recorded that the resident was taken to the hospital and returned with no injuries noted, and the fall report identified a malfunction of the seat belt as the root cause. The Administrator later stated that the resident had been in the wheelchair with a seat belt on, which allegedly came unlatched when the van stopped suddenly, causing the fall. The resident himself reported that he hit the dashboard and that the wheelchair landed on top of him, and he stated he did not remember whether he or the wheelchair had been buckled but believed they must not have been secured for the wheelchair to end up on top of him. Staff accounts regarding proper securement were inconsistent. The van driver (a CNA) stated that there are four clamps to lock the wheelchair in place and a seat belt for the resident, and she asserted that she had buckled both the resident and the chair before starting the trip. However, another CNA stated she knew the resident was not buckled in properly on the day of the incident and reported that the resident told her he was not buckled in. Facility policy in the Drive Safe Program states that the driver is responsible to ensure all passengers are securely seated and using seat belts. Following the incident, subsequent clinical documentation and imaging confirmed that the resident sustained an acute non-displaced right lateral 10th rib fracture and an acute distal clavicle fracture related to the fall in the van.
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