F0689

E

Failure to Secure Resident During Van Transport and to Assess and Document Post-Fall

Shreveport, Louisiana Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was properly secured during facility van transport, to assess the resident after a fall in the van, and to promptly report and document the incident. The resident had multiple significant diagnoses, including type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis following cerebral infarction, glaucoma, bilateral below-knee amputations, and muscle wasting and atrophy, and used a wheelchair for mobility. The resident’s care plan identified a high risk for falls related to being a bilateral amputee and wheelchair-bound. Facility policy for accidents and falls required that residents not be moved until evaluated by a licensed nurse, that the nurse in charge be notified, that a thorough head-to-toe assessment be completed, that the physician be notified for follow-up orders, and that an accident/incident report and appropriate documentation be completed by the end of the shift.

On the date of the incident, the resident was being transported by facility van to a medical appointment with a CNA who was also the van driver, another CNA, and a complainant present. Multiple interviews indicated that while the wheelchair was secured at the front and back on the van floor, the chest strap and lap safety belt that hook together across the resident were not in place. The resident, the complainant, and the accompanying CNA reported that the chest strap did not work or was not snapped in and attached, and that they proceeded with transport without the chest or lap strap across the resident. During transport, the van driver applied the brakes at a light, and the resident came out of the wheelchair and fell to the floor of the van, ending up on the floor facing the back of the van. Staff then pulled the van over, opened the back, used the ramp, and repositioned the resident back into the wheelchair, which took an extended period of time, and then continued on to the scheduled appointment without the chest strap or lap belt in place.

Following the incident, the facility did not follow its own accident and fall policies. The van driver did not call the facility at the time of the fall so that a nurse could assess the resident before he was moved or before proceeding to the appointment. The resident’s nurse reported not being informed of the fall and therefore did not complete an assessment. The incident was not entered on the facility’s incident log, and no accident/incident report was completed by the end of the shift or thereafter. The DON, administrator, and corporate nurse later acknowledged that the chest and lap safety belts were not used, that the van driver should have called the facility and that the resident should have been assessed for injuries, and that an incident report and documentation should have been completed. The resident reported that no one checked on him or asked if he was okay upon his return to the facility, and the complainant reported the resident had bruises on his residual limbs after the fall.