F0689

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Resident Ejected from Wheelchair During Transport Due to Failure to Secure Lap Belt

Lees Summit, Missouri Survey Completed on 09-18-2025

Penalty

No penalty information released

Summary

A deficiency occurred when a resident was not properly secured with a lap belt in the facility van during transport, resulting in the resident being ejected from their wheelchair. The resident, who was cognitively intact but had significant visual impairment and was at risk for injury, was being transported for a scheduled medical procedure. The wheelchair was secured to the van, but the resident was not fastened with the required seatbelt, despite the facility's policy and the driver's training. The resident was unable to secure the lap belt independently and did not request assistance from the driver.

During the transport, the driver made a series of turns, and the resident was thrown from the wheelchair, hitting their face on the van's console and sustaining facial injuries, including a bleeding and swollen lip and bruising. The driver did not immediately call 911 or notify facility staff of the incident, instead stopping at a convenience store to provide the resident with a napkin and then continuing to the scheduled appointment. The resident was later taken to a dialysis appointment, where a nurse noticed the injuries and contacted the facility's DON. Only after this notification was the resident sent to the emergency department for evaluation.

Interviews and record reviews confirmed that the driver had received training on proper transport procedures, including securing residents with seatbelts and following emergency protocols. The driver admitted to not securing the resident and not following required notification procedures after the incident. The facility's investigation determined that the driver failed to perform safety procedures as trained, leading to the resident's injury during transport.

Removal Plan

• Educate staff on appropriate transportation policies and procedures.
• Implement a checklist for transporting residents.
• Institute supervisor ride-along with drivers for training.
• Implement a system of auditing the checklists.