F0689

G

Resident Not Properly Secured in Transport Van, Resulting in Fractures

Philadelphia, Pennsylvania Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was adequately secured in a transportation van, resulting in the resident sliding out of the wheelchair and sustaining fractures. The facility’s wheelchair transport policy, revised in June 2025, addressed moving residents who cannot transfer without assistance to meet their physical, social, psychological, or spiritual needs, but the report does not describe specific procedural steps from that policy being followed at the time of the incident. The resident involved was an 85‑year‑old, cognitively intact individual (BIMS 15), non‑ambulatory for seven years, requiring a mechanical sit‑to‑stand lift for transfers, and admitted with multiple diagnoses including chronic pain, macular drusen, anxiety disorder, major depressive disorder, muscle weakness, osteoarthritis, and edema. These conditions made the resident dependent on staff for safe mobility and transport.

On the day of the incident, the resident went out with family for a birthday celebration using a facility wheelchair van. The van driver reported that at approximately 2 p.m. he picked up the resident and the resident’s daughter, secured the wheelchair to the four floor anchor points, and applied the van’s seat belt, with the daughter seated in the back passenger seat. About 15 minutes into that outbound trip, the resident reported slipping; the driver stopped and readjusted the seat belt, and the resident attributed the slipping to pants material and the wheelchair cushion. The remainder of the outbound trip was completed without further reported issues. Later that evening, the driver returned to pick up the resident and daughter, again wheeled the resident into the van, and strapped the resident in as he stated he had done earlier.

During the return trip, within a few minutes of departure, the resident again reported feeling loose or slipping. According to the driver, he told the resident he would stop to readjust the belt, and the resident said to keep going; the daughter asked if the resident was sure, and the resident again affirmed. The driver stated he was driving at or below the speed limit in heavy traffic. Shortly thereafter, the resident reported slipping again; when the driver stopped and opened the door, he found the resident sitting on the wheelchair footrest. The driver and the daughter attempted but were unable to lift the resident back into the chair. The daughter then requested that they return to the facility. The resident and daughter both reported that the resident slid down from the wheelchair during the ride, with the daughter stating that on the return trip she believed the resident had been strapped in the same way as on the way over, but a few minutes into the ride the resident began to feel loose and then slid down off the chair while the van was going through a busy intersection.

Upon arrival at the facility entrance, the supervising RN found the resident on the floor of the handicap van, half sitting and half lying, with legs beneath the body, having slid out of the wheelchair during the ride. The RN documented that the resident had been secured with the van seat belt in a transport wheelchair that was itself secured to the van floor with four straps, and that the daughter had tried but was unable to prevent the resident from sliding out. The RN was unable to complete a thorough assessment or obtain vital signs due to the resident’s position in the van, and 911 was called immediately. Hospital records documented a left periprosthetic distal femur fracture and a right distal tibial shaft fracture resulting from slipping forward under the wheelchair seat belt. In interviews, the DON and Nursing Home Administrator confirmed that the facility determined, after having the van driver demonstrate the belting method, that the driver did not properly secure the resident in the transportation van by failing to ensure the wheelchair was properly belted under the arms of the wheelchair to obtain and maintain maximum securement.

The total driving distance from the outing location back to the facility was approximately 5.4 miles, with an estimated driving time of 19 minutes. During interviews, facility leadership acknowledged that the van used was a facility transport van and that the resident was in a standard wheelchair. The DON stated that the van driver had fastened the resident’s seat belt and that, based on the facility’s review, the method used did not provide maximum securement. The Director of Maintenance described his role in evaluating the vans and training staff on securing residents, including the use of existing cross‑strap seat belts and the need for additional lap belts for certain wheelchair configurations, but these details were provided in the context of his general responsibilities and not as actions taken before the incident. Overall, the report establishes that the resident was not adequately secured in the transportation van, leading to the resident sliding out of the wheelchair and sustaining significant fractures requiring hospital transfer and surgery.