F0689

J

Improper Wheelchair Securement During Van Transport Leads to Resident Injury

Ranger, Texas Survey Completed on 01-15-2026

Penalty

Fine: $21,645

Summary

The deficiency involves the facility’s failure to ensure the resident environment remained as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents during van transportation. A female resident with a history of left femur fracture, anxiety, and depression, and with moderate cognitive impairment (BIMS score of 10), required substantial/maximal assistance for sit-to-stand and car transfers, and walking was not attempted due to her medical condition. Her care plan identified limited physical mobility related to a fractured hip and indicated she required assistance by one staff to walk. Despite these needs, she was transported in the facility van in a wheelchair and was not properly secured using the required 5‑seatbelt restraint system.

On the day of the incident, the CNA assigned to transport the resident took her to what turned out to be the wrong orthopedic office and then returned her to the van to go to the correct location. The CNA reported pushing the resident up the wheelchair ramp, locking the wheelchair wheels, and fastening the two rear seatbelts that secured the wheelchair to the floor. She then moved to the front of the van and stated she fastened the remaining three belts, which included two front straps securing the wheelchair to the floor and a lap belt over the resident’s lap. While driving, the van began to overheat in a construction zone, and as the CNA slowed down after seeing a yellow light, she heard a noise and saw that the resident’s wheelchair had flipped backwards, with the resident on the floor at the back of the van. The CNA reported that the resident’s front safety belt was unclamped and that she had to unbuckle the lap belt to move the wheelchair to reach the resident.

The resident was transported by EMS to the hospital, where records documented an acute subdural hematoma and a cervical fracture following a fall from a wheelchair while being transported in a van. When interviewed in the hospital, the resident, who was wearing a cervical collar, recalled that the CNA hit the brakes and the wheelchair flipped; she stated she did not know if all straps were fastened and that she had not unfastened any safety belts herself. Facility staff later tested the van’s 5‑belt restraint system with an empty wheelchair and found that when all four floor straps and the lap belt were secured, the wheelchair could not be flipped, and even with the lap belt removed or one front strap unfastened, the chair still would not budge. The wheelchair only flipped backwards when both front straps were unfastened, leading the Administrator to state that the only way the chair could have flipped was if the two front safety belts were not fastened.

Further review revealed systemic failures related to transportation safety. The Office Manager initially stated that transportation aides were trained and had demonstrated competency in wheelchair securement and safety belt placement before transporting residents, but later acknowledged there was no evidence of such training or competencies for the CNA involved or for the current transportation aide. Personnel file reviews for both aides showed no documentation of training related to transportation safety or wheelchair securement, despite a facility policy requiring that staff responsible for transportation be trained and demonstrate competency in wheelchair securement procedures, with competency documented prior to independent transport duties. Additionally, the Administrator reported that the van had no maintenance logs, no records of routine safety checks, and was not inspected routinely, even though the van had recently overheated during the incident. These inactions and lack of documented training, competency validation, and vehicle safety oversight contributed to the improper securement of the resident’s wheelchair and the resulting accident and injuries.

Removal Plan

• Ceased all resident transportation via van and wheelchair transfers requiring safety restraint usage; ceased all other facility transports unless staff were trained by nursing staff trained in safe transport and proper safety restraints.
• Required verification that safety restraints are applied correctly and staff supervision is present prior to movement; implemented and used a transport check sheet/checklist located at the nurses station; trained all transport staff on proper use of the transport checklist.
• Required that no resident is transported or transferred using the facility van until safety checks are completed and documented; completed staff in-service/sign-off for training and notification of safety checks.
• Required licensed nursing staff trained in van safety transportation to provide supervisory oversight for all transfers involving wheelchairs.
• Completed a 100% audit of all residents transported outside the facility and identified residents likely to be affected; updated care plans and implemented additional supervision for any resident identified as high risk.
• Established a standardized transportation and wheelchair restraint checklist process; implemented a Skilled Nursing Facility Transportation Safety Checklist and Wheelchair Van Restraint Safety Checklist for all nursing staff.
• Provided staff education and competency validation (return demonstration) for all staff involved in resident transfers/transportation (nurses, CNAs, drivers) on wheelchair brake locking, proper restraint use, and supervision requirements; prohibited staff from transport duties until competency is demonstrated.
• Trained all nurses on proper procedure for transports with a wheelchair upon hire and annually.
• Updated care plans to clearly identify supervision and transport requirements.
• Created/revised transportation and accident prevention policy to include training requirements, safety checklist, transportation safety, and restraint checklist.
• Adopted a zero tolerance policy for noncompliance with transportation safety procedures; made in-service mandatory for current staff and before starting first shift for new staff.
• Implemented supervisory sign-off requirement for all external transports.
• Implemented weekly preventive maintenance checks for wheelchairs and van restraints.
• Implemented monitoring/oversight: DON/designee conducts daily audits of transportation documentation, then weekly; reviews findings during QAPI meetings; initiates immediate corrective action for any noncompliance.
• Incorporated transportation safety training into new hire orientation and required annual competency validation for all applicable staff; continued ongoing QAPI monitoring to ensure sustained compliance.
• Established a standardized maintenance checklist to be reported monthly in QAPI meetings with the IDT.