Failure to Secure Resident During Transport
Summary
The facility failed to ensure a resident dependent on staff was safely secured in a wheelchair with an appropriate seat belt during transportation in a facility van to a physician's visit. This resulted in Immediate Jeopardy when a transport driver abruptly stopped the facility van, causing the resident to come out of her wheelchair and land on the floor, sustaining a hematoma, increased pain, and lacerations that required sutures. The incident affected one of three residents reviewed for the use of assistive devices during transportation, with a total of 23 residents utilizing wheelchairs and the transport van who would require seat belts engaged. The resident involved was an elderly female with multiple diagnoses, including morbid obesity, fibromyalgia, disc degeneration, cerebral infarction, muscle weakness, gait abnormalities, chronic respiratory issues, polyarthritis, and hypertension. She was cognitively intact and required transportation via wheelchair. During the trip, the transport driver failed to properly secure the resident, and when the van stopped abruptly, the resident slid out of her wheelchair and landed on the floor. The driver then drove back to the facility with the resident lying unsecured on the floor, further endangering her. Upon returning to the facility, the resident was assessed and found to have a laceration on her right knee, which required sutures, and other injuries. The transport driver did not follow the facility's policy of calling 911 immediately after the incident and instead returned to the facility. The facility's investigation revealed that the driver had been previously educated on the proper transportation protocols but failed to adhere to them during this incident.
Removal Plan
- Resident#15 arrived back at the facility and was immediately assessed by Licensed Practical Nurse (LPN)/Unit Manager #37 and former DON #38.
- Nurse Practitioner (NP) #62 was notified and ordered Resident #15 to be sent to the ER.
- 911 was called by LPN #39.
- Former DON #38 notified Resident #15's family.
- EMS arrived at the facility and transported Resident #15 to the ER for further evaluation and treatment.
- Former DON #38 and LPN #39 updated Resident #15's care plan to include: Send Resident #15 to the ER, wheelchair safety education for the resident, provide an escort for all transport/appointments and skin/laceration care.
- The Administrator ceased all transportation for in-house facility transports.
- The Administrator and former DON #38 interviewed FTD #34 and an investigation started regarding the entire incident and actions that transpired during the incident.
- A van inspection was completed by Maintenance Director #41 and no mechanical issues or malfunctions were discovered.
- FTD #34 was interviewed, and a written statement was obtained. FTD #34 received a final level Corrective Action Form conducted for failure to follow transportation protocol. FTD #34 was suspended pending an investigation of the incident to allow for investigation, education, and ensure no other incidents had occurred. FTD #34 did not return to work and made no other transportation after this incident for the facility.
- The transportation policy was reviewed with the three staff members authorized to complete resident transports. Maintenance Director #41, Transportation Driver (TD) #30, and FTD #34.
- The designated facility TD will perform inspections for the transportation vehicle/equipment to ensure safe and functional operation every day prior to any transportation needs.
- These inspections are to be verified by Maintenance Director #41 after each inspection is completed for the next 30 days then the facility will transition to three times weekly for three months and then monthly ongoing.
- Should Maintenance Director #41 not be available to complete this verification, it will be performed by Regional Director of Maintenance #40/Designee.
- Central Supply Coordinator/Transportation Scheduler #31 conducted an audit of a 30-day lookback of all resident's transportation provided by facility to ensure no other incidents had occurred.
- No concerns were identified from this audit.
- Resident #15 was immediately switched to another transportation service. The Administrator secured an outside transportation company for all facility transports until further notice. All appointments were transferred to the outside provider.
- To monitor for ongoing compliance, Maintenance #41/Designee will audit the facility van three times weekly for three months and then will perform inspections monthly ongoing to ensure the transportation vehicle/equipment is safe and functioning.
- To monitor for ongoing compliance, Maintenance Director #41/Designee will audit via observations and return demonstrations of the facility transportation drivers weekly for one month and then monthly for three months to ensure residents are secured appropriately and safely.
- To monitor for ongoing compliance, Maintenance Director #41/Designee will supervise one transportation run monthly for one year to ensure appropriate transportation methods are in place per the facility's policy. This was implemented and started when in-house transports were resumed. All results of the audits will be included in each QAPI with any findings.
- Resident #15 was transported back to the facility. Resident #15 sustained a laceration on her right knee and seven sutures were placed. All other imaging and diagnostics tests were negative.
- Former DON #38 interviewed Resident #15 and received her verbal statement.
- Resident #15 stated she was riding in the transport van and when the driver (FTD #34) stopped, she slid out of her wheelchair. Resident #15 indicated she stayed on the floor of the van until the driver got back to the building and then she went to the hospital. Resident #15 was educated on safety during transports.
- Regional Director of Maintenance #40 conducted one-on-one (1:1) training, conducted competencies and check offs with a return demonstration with all three authorized transportation drivers (Maintenance Director #41, FTD #34 and TD #30) to ensure previous education was understood and to remain compliant with safety precautions. FTD #34 was not reinstated afterwards due to FTD #34 providing the facility with his resignation.
- Education included: Vehicle safety, Safety and Health Programs, Mandatory Transport Driver Training, Drivers Training Classroom Curriculum, Company Vehicle Driver Program (Fleet Safety Program), Safer Transportation of Wheelchair Passengers, Passenger Safety During Transport, New Driver Request Forms, Transport Staff Performance Agreement, Emergency Supplies Check list, Monthly Preventative Maintenance, and Quarterly Vehicle Inspection Reports and initiated immediately. The policy was reviewed again by Regional Director of Maintenance #40 with the Administrator, Maintenance Director #41, FTD #34 and TD #30. Regional Director of Maintenance #40 conducted competencies and check offs with a return demonstration to ensure previous education was understood and to remain compliant with safety precautions.
- The transportation policy was reviewed by the Administrator. All facility transportation remained stopped and no new changes were implemented to the policy. All facility transports were being conducted by an outside provider.
- A Post Traumatic Stress Disorder (PTSD) screen was completed on Resident #15 and added to the care plan by Director of Social Services #66. The following new interventions were added: To assist and identify what triggers PTSD episodes, encourage slow/deep breathing exercises, reassuring conversation with pleasant topics, observe for increased agitation, anxiety, and offer quiet areas and comfort items, observe resident in group situations and prevent resident from becoming over stimulated, sudden unexpected noises, and new/tv programming may also trigger resident incident, offer quiet area, speak in calm quiet voices and offer reassurance.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with attendees including: The Administrator, Former DON #38, Medical Director (MD) #64, LPN/Clinical Manager #70, Maintenance Director #41, LPN/Unit Manager #37, Central Supply Coordinator #31, LPN #39, [NAME] President of Risk Management #72, Regional Director of Clinical Operations (RDCO) #78, and Regional Director of Operations (RDO) #80 regarding this incident and discussion was held regarding transportation protocols and safety, falls, and steps the facility is taking moving forward to prevent further reoccurrence of the incident.
- The vehicle insurance company obtained a report of the incident and once the insurance started their investigation their findings were handled through the insurance. No results/findings have been returned to the facility.
- Resident #15 had an outside appointment at a physician's office and did not have any identified concerns during the transport via the outside provider.
- Interviews with TDs #30 and #58 and Maintenance Director #41, each stated they were in-serviced and educated on properly transporting residents and are utilizing the complete Q'Straint system.
- Review of four (#27, #50, #38 and #21) additional resident's medical records who required assistive devices for transportation revealed no concerns.
- Review of the facility's Transportation Safety Audits including Inspections and Ride Along's revealed the audits were performed as scheduled with no issues identified.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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