F0689

J

Failure to Secure Wheelchair-Bound Resident With Seat Belts During Van Transport

Warsaw, New York Survey Completed on 02-09-2026

Penalty

Fine: $21,645

Summary

The deficiency involves the facility’s failure to ensure that a resident was safely secured in the facility’s wheelchair transport van, resulting in the resident being thrown from the wheelchair during an abrupt stop and sustaining injuries. The resident had diagnoses including post-orthopedic aftercare following a hip fracture repair, congestive heart failure, and COPD, and was assessed as cognitively intact, able to understand and be understood by others. The resident’s care plan and Kardex documented that the resident was dependent on staff for wheelchair mobility off the unit and required extensive assistance of one staff member with a rolling walker and gait belt for transfers.

On the day of the incident, the resident was being transported back from an outside medical appointment in the facility’s van by a driver and a transport aide. The wheelchair was anchored to the van floor with four anchor points, but the shoulder and lap belts were not applied. The facility’s accident and incident report documented that the van was traveling at approximately 45 miles per hour when traffic in front stopped abruptly, causing the driver to brake suddenly. As a result, the resident, who was sitting upright in the wheelchair, fell forward out of the wheelchair onto the van floor and reported pain to the nose and knees. Emergency Medical Services were called, and the resident was transported to the emergency room, where they were diagnosed with a nasal fracture and abrasions, and reported associated pain.

Interviews and documentation revealed conflicting accounts regarding whether the resident refused the seat belt, but confirmed that the required shoulder and lap belts were not in use at the time of transport. The facility’s five-day investigation documented that the driver admitted to not securing the resident with the seat belts, stating, "No, I forgot to put it on." The transport aide stated that this was their first day working independently, that the resident had refused the seat belt, and that the driver said it was acceptable to proceed. The accident and incident report did not document any refusal by the resident to wear the belts, and in a later interview the resident stated they did not refuse to fasten the seat belt and did not know why staff had not fastened it. The Medical Director stated that if the resident had been properly restrained according to Department of Transportation guidelines and facility policy, the fall from the wheelchair and resulting harm would not have occurred. Facility leadership, including the Assistant Administrator, Director of Maintenance, and DON, stated that drivers were trained not to move the van until all passengers were strapped in and that staff should have contacted a supervisor and refused to transport if a resident did not have safety restraints applied.

The facility’s written policy for operation of the transport van at the time of the incident included training on the wheelchair lift and restraint system but did not include a verification check system to ensure residents were appropriately secured prior to transport or instructions on what to do if a resident refused safety requirements. The Director of Maintenance confirmed that, at the time of the accident, the wheelchair was secured to the floor but the shoulder and lap belts were not applied, which allowed the resident to be thrown from the wheelchair during the abrupt stop. The surveyors determined that this failure to provide adequate supervision and assistance devices to prevent accidents resulted in actual harm to the resident and constituted Immediate Jeopardy and Substandard Quality of Care, with the likelihood of serious harm, serious impairment, serious injury, or death to residents’ health and safety.

Removal Plan

• Driver #1 was terminated.
• Transport Aide #1 was re-educated.
• The policy titled "Operation of the 2011 Ford Passenger Van" was revised to include a three-level safety verification process for every resident transported.
• Transportation verification logs were created for each trip to document each verification step and signature of completion.
• Safety signage inside the transport van was enlarged and relocated.
• 100% of transportation staff were educated.
• Nursing, recreational, therapy, and social work staff were educated regarding the verification system, transport policy, and resident safety.
• Training was continued and expanded to include nutritional and housekeeping services staff.
• Transportation audits were conducted to monitor corrective actions and ensure implementation of facility protocols for resident safety during transportation.
• Audit results were reviewed weekly by Administration and reported during monthly QAPI meetings.