Failure to Train Van Staff on Wheelchair Securement Leads to Resident Injury
Summary
The deficiency involves the facility’s failure to ensure transportation staff were properly trained according to the wheelchair securement system manufacturer’s instructions and to respond appropriately when a resident reported wheelchair movement in the transport van. One resident, R3, had a care plan documenting multiple diagnoses including acute on chronic diastolic congestive heart failure, morbid obesity, hypertension, localized edema, depression, anxiety disorder, heart disease, and chronic kidney disease. R3 had weakness, bilateral lower extremity edema, impaired mobility, used a manual wheelchair for locomotion, and required staff assistance for activities of daily living and transfers. On the day of the incident, R3 was being transported in the facility’s van when the wheelchair moved and tipped forward while the van was in motion. According to the facility’s investigation and staff interviews, the van driver (V13) transported R3 to the van in a wheelchair, applied wheelchair restraints and a lap belt, and began driving down a hill away from the facility. Shortly after the van began moving, R3 felt the wheelchair move and alerted the driver that the wheelchair was moving; the driver reportedly told R3 that she would be okay and continued driving. The driver then heard R3 scream, looked in the rearview mirror, and saw the wheelchair tipped forward with R3 leaning forward and attempting to brace herself. The driver parked, assessed the situation, then drove the van back around the parking lot to the main entrance to obtain help. When the DON (V2) and an LPN (V11) entered the van, they observed the wheelchair tipped forward, R3 on the floor with the left leg under her, blood present, and the restraint straps still attached and pulled taut, making it difficult to free R3 from the wheelchair and seatbelt. Emergency department and orthopedic records document that R3 fell out of the wheelchair in the transport van, sustained multiple lacerations to the lower extremities, and suffered fractures of the left tibia and fibula, including a proximal tibia fracture, fibular head fracture, distal fibula fracture with extension to the ankle syndesmosis, and an anterior inferior tibiofibular avulsion fracture. Interviews and record review showed that the van driver stated she was not formally trained on driving the van or securing residents, had only received a safety checklist, and had no supervised training or daily safety checklist for the van. The maintenance director (V5) claimed to have trained the driver and had signed training checklists, but the forms were photocopied, lacked the trainee’s signature, and the driver denied receiving the post-incident training documented. Observation of the driver securing another resident (R8) in the van showed the J-hooks of the mechanical retractable system attached to the wheelchair armrests at an improper angle with twisted straps, and another resident (R12) reported the driver had repeatedly used armrests as anchoring points. The manufacturer’s manual and the facility’s own training checklist required attachment of tie-down hooks to a solid wheelchair frame at an approximate 45-degree angle, with no twisting of straps, and specified that the system should only be operated by individuals who fully understand its use, requirements that were not met in this case. Additional interviews and document review revealed that the facility did not have a transportation policy at the time of the incident, despite the transportation aide job description stating that the purpose of the role was to provide safe and timely transportation in compliance with federal, state, local, and corporate requirements and to assume responsibility for residents’ safety while transporting. The driver’s training forms referenced following the manufacturer’s guide for specific instructions on how to secure the wheelchair and client and included a detailed checklist for proper wheelchair securement and patient restraint, including inspection of straps, correct floor anchor positioning, attachment to appropriate anchor points on the wheelchair frame, and avoidance of strap twisting. However, the observed practices of the driver and the maintenance director’s inability to accurately demonstrate use of the specific mechanical retractable system in the van showed that these procedures were not effectively taught or followed. These combined failures in training, policy, and response to the resident’s report of wheelchair movement led to R3 sliding forward in the wheelchair, the wheelchair tipping forward, and R3 falling onto the van floor, resulting in significant injury.
Removal Plan
- Conducted in-service education on proper securing of resident wheelchairs in the transportation van, including the facility policy, for the approved transportation drivers and the maintenance director
- Utilized a video training about the securement straps and seat belts in the transportation van for the approved transportation drivers and the maintenance director
- Conducted return demonstrations for the approved transportation drivers and the maintenance director
- Developed a facility policy for securement of wheelchairs in the transportation van
- Reviewed the job description for the transportation drivers
- Developed a list of approved transportation drivers
- Conducted a Quality Assurance Meeting to discuss the Immediate Jeopardy citation, needed training, proficiency checklist, list of approved drivers, review of transportation aide job description, development and corporate approval of facility policy, and abatement plan
- Conducted audits for residents utilizing the facility van to be transported to appointments
- Confirmed the transportation drivers completed proper demonstration for securement technique of an occupied wheelchair into the facility transportation van
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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