F0689

J

Failure to Properly Train and Secure Wheelchair-Bound Resident During Transport Resulting in Injury

Alva, Oklahoma Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a wheelchair-bound resident was protected from accidents and injuries during transportation. A quarterly assessment dated 10/27/25 showed Resident #20 had intact cognition with a BIMS score of 13, was dependent for positioning, and was wheelchair bound. The facility’s Transportation and Vehicle Use policy, dated 12/26/25, required all drivers to complete defensive driving, wheelchair and mobility device securement, resident safety and transfer training, facility transportation orientation, and annual refresher training. The policy also required that wheelchair users have wheelchair brakes locked, a four-point tie-down system secured, and lap and shoulder belts applied, with drivers visually confirming securement before moving the vehicle. However, employee files for transporter #1 and transporter #2 did not contain documentation of skills checks or training for properly transporting residents, and the DON stated there was no annual competency or training program for drivers, with current drivers informally training new hires.

On 12/30/25, transporter #1 improperly secured Resident #20 in the transport vehicle, resulting in the resident’s wheelchair tipping onto its side when the driver swerved to avoid another vehicle. A state reportable incident documented that the resident sustained a fractured rib and moderate spleen damage requiring admission to a hospital trauma center. A nursing note dated 12/31/25 confirmed a rib fracture and a grade 2 spleen injury. A significant change assessment dated 01/12/26 later showed the resident’s BIMS score had declined to 12, indicating moderate impairment for daily decision making, and continued dependence for positioning and wheelchair use. During interview, the resident reported that while traveling to a doctor’s appointment, the vehicle swerved on the highway and the next thing they knew they were on the floor, after which they were hospitalized for several days and returned to the facility, still experiencing pain and discomfort requiring medication. Transporter #1 stated they had placed the resident facing the front of the van, used the four-point strap system and a seatbelt, but believed the straps were not tight enough, and reported having received training only once, 15 years earlier, with no subsequent training. The DON confirmed transporter #1 did not secure the wheelchair tightly enough and that scheduled defensive driver training for transportation staff had not yet been completed.

Removal Plan

• Stopped resident transport
• Conducted a mandatory in-service and hands-on training for all staff assigned to resident transport
• Trained staff on correct wheelchair orientation in the vehicle
• Trained staff on engaging wheelchair brakes
• Trained staff on proper four-point tie-down attachment to the wheelchair frame
• Trained staff on proper strap tightening until no movement remains
• Trained staff on application of a separate occupant lap and shoulder belt
• Trained staff on performing a final tug test and visual verification before vehicle movement
• Trained staff on the procedure to follow if securement cannot be achieved
• Required each designated transporter to complete a hands-on demonstration on the facility transport vehicle
• Administrator and Director of Nursing completed and signed a competency validation checklist for each transporter