Improper Wheelchair Securement During Van Transport Leads to Resident Injury
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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