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F0689
G

Failure to Secure Resident with Seatbelt During Van Transport Results in Injury

Minot, North Dakota Survey Completed on 11-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident was being transported back to the facility in a van and was not properly secured with the shoulder strap seatbelt. The transporter and the resident were engaged in conversation while the transporter was securing the wheelchair to the floor of the van, resulting in both parties forgetting to secure the seatbelt that crosses over the resident. During the trip, the van had to stop abruptly at a stoplight, causing the resident, who was leaning forward in the wheelchair, to fall out. The resident sustained an abrasion, bruising, swelling to the right knee, and complained of shooting pain from the knee to the hip, which led to a hospital admission and surgery for a fractured femur. Review of the facility's records and interviews confirmed that the transporter did not realize the shoulder strap was not secured until after the resident fell. Documentation showed that all van drivers had completed competency verification and training prior to becoming transporters, and interviews with other residents indicated that they typically felt safe and were secured with the crossover belt during transport. However, in this instance, the required supervision and use of assistance devices to prevent accidents were not provided, directly resulting in the resident's injury.

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