Failure to Secure Residents During Van Transport Results in Neglect
Summary
The facility failed to protect two residents from neglect during transportation to medical appointments in the facility van. One resident, a male with diabetes, flaccid hemiplegia, and moderate cognitive impairment, was not secured with a seatbelt while being transported in his wheelchair. Despite requesting the seatbelt, the transport aide did not secure him, stating she did not like the seatbelt. During the trip, the aide had to brake suddenly due to traffic, causing the resident to fall out of his wheelchair onto the floor of the van. The resident remained on the floor for approximately 30 minutes until returning to the facility, where it took four staff members to assist him out of the van. The resident reported feeling unsafe and stated the aide was aware of his need for a seatbelt but failed to provide it. Another resident, a female with cerebral infarction, bilateral above-knee amputation, diabetes, and end-stage renal disease, was also transported without being secured by a seatbelt. She reported asking the transport aide to use the seatbelt, but the aide claimed it did not work. During the trip, the aide braked suddenly, and the resident had to brace herself to avoid falling out of her wheelchair. The resident expressed feeling unsafe and unwilling to be transported by the same aide in the future. Both incidents involved the same transport aide, who had received training and return demonstrations on securing residents and using seatbelts but failed to follow procedures during actual transports. Interviews with facility staff and review of training records revealed that the transport aide had been trained and checked off on competencies related to securing wheelchairs and using seatbelts. However, the aide stated she was unsure how to secure residents with seatbelts and did not feel properly trained, despite documentation of completed training and return demonstrations. The facility's policies required staff to ensure residents were safely secured during transport, but these procedures were not followed, resulting in residents being placed at risk of injury. The facility identified these failures as neglect, as defined in their policy, due to the lack of necessary services to prevent physical harm and emotional distress.
Removal Plan
- Resident #10 was assessed by the charge nurse for injuries, physician was notified, orders for x-rays were obtained, and responsible party was notified.
- Residents with appointments requiring wheelchair transport were identified as affected by use of the current van.
- Safe Surveys were conducted with other residents transported by facility staff in wheelchairs and those not in wheelchairs.
- Van driver was retrained on facility safety procedures for strapping residents into the wheelchair using tie downs and seatbelts by another staff member.
- Nursing Home Administrator observed retraining of van driver by a more senior staff member with van experience.
- Facility van was removed from service for transporting residents in wheelchairs.
- Van will not be put back in service until the complete restraint system, including seatbelts for wheelchairs, is replaced.
- Facility purchased a new van; residents requiring wheelchair transport will be transported by sister facilities until all staff are checked off for operations of the new van.
- Administrator, surveyor, and two facility-approved drivers observed sister facility driver demonstrate wheelchair tie downs and seat belting prior to transporting a resident.
- One of the facility's van drivers accompanied the resident and the driver on the appointment.
- Administrator reviewed van driver competencies completed on the vehicle.
- Residents will not be transported in the existing van in a wheelchair until after the restraint system is updated and all drivers are checked off on securing the wheelchair with tie downs and seatbelt system.
- Both van drivers have been in-serviced not to use the wheelchair van until the system for securing wheelchairs is replaced and competencies with return demonstration are completed by the NHA/designee.
- Van driver was suspended pending investigation.
- Van was inspected by a company specializing in wheelchair transport vehicles; technician stated system is functioning but old and needs updating.
- NHA called and emailed to request the inspection report.
- NHA/designee in-serviced all staff on state provider letter regarding Abuse, Neglect, Exploitation, Misappropriation of resident property, and other incidents.
- All staff, including new hires and agency, are required to complete the in-service prior to starting their next scheduled shift.
- NHA/designee in-serviced all staff that drive the van on safety and emergency procedures with a post-test; staff who fail the post-test will be retrained and retested.
- Staff will not be allowed to operate the facility van until they have successfully passed the post-test.
- NHA/designee performed competencies and return demonstration on emergency procedures, operating the wheelchair lift, test driving, and reviewing a YouTube video for strapping the wheelchair and buckling the person in the wheelchair for all transport staff.
- Staff will be suspended from driving until competencies are passed; competencies with return demonstration will be completed on hire, annually, and as needed.
- NHA and Regional Nurse Consultant reviewed the Van Driver Orientation List and added instructions for emergency procedures, including procedures for if a resident falls out of seat or chair (pull over, call 911, notify NHA).
- NHA/designee will conduct audits with observation for proper securement of wheelchair and seatbelt use.
- NHA/designee will interview residents transported by facility staff using a set of safety-related questions.
- Ad-Hoc QAPI held with Medical Director, NHA, DON, ADON, Regional Nurse Consultant to review the alleged deficiency, policy and procedure, and the plan of removal of immediacy.
- NHA will be responsible for ensuring the plan is completed.
- RDO/designee will provide oversight by observation and record reviews to ensure the plan of removal items are reviewed and completed, continuing monitoring.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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