Wheelchair Not Properly Secured During Van Transport Resulting in Resident Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safe transport for a resident using a wheelchair in the facility’s transport van, resulting in an accident. An [AGE]-year-old male resident with a history of cerebral infarction with hemiplegia, osteoarthritis, Type II diabetes, major depressive disorder, and overactive bladder, who used a wheelchair for mobility but had intact cognition and independence in most ADLs, was being transported back to the facility from an appointment. According to the facility’s self-report and EMR documentation, as the van turned a corner, the resident’s wheelchair tipped over, causing him to hit the back of his head and sustain a contusion. Record review showed that the van driver involved in the incident stated in a written statement that she had secured the resident’s wheelchair with straps but acknowledged that one of the straps was not at the lowest position. The driver had previously completed driver training and a safety program. The RN Supervisor’s written statement documented that she was notified of the incident by the driver, went to the van’s location, assessed the resident, and then returned him to the facility before the physician was notified and recommended hospital evaluation. The resident was transported to the hospital via ambulance and returned the same day with a diagnosis of head contusion and mild headache, with no new orders. During interviews, the resident confirmed that his wheelchair tipped over when the van turned a corner and that he hit his head on a bar, but he denied that the van was traveling too fast. Additional interviews with current van drivers and transport aides indicated that they had received training and hands-on instruction in wheelchair restraint and passenger securement, and observations of them securing a proxy resident in the van showed proper use of wheelchair tie-downs and seat belt restraints. The DON stated that nursing staff are responsible for ensuring residents are seated in appropriately sized wheelchairs with footrests before transport, and that charge nurses and unit managers must verify residents are adequately prepared for van transport. The facility’s transportation policy required wheelchair residents to be secured per manufacturer instructions using proper tie-downs, which was not fully adhered to in this incident as one strap was not positioned correctly, leading to the unsafe transport condition.
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