Failure to Use Wheelchair Lap/Shoulder Restraint During Van Transport Resulting in Resident Ejection
Summary
The deficiency involves the facility’s failure to ensure a resident being transported in a facility van was protected from accident hazards through proper use of a lap and shoulder seatbelt restraint. A cognitively intact resident who used a wheelchair for mobility and was dependent for transfers was transported from a cardiology appointment in a company-operated van. The resident had significant medical conditions including atrial fibrillation, heart failure, prior CVA with hemiplegia, DVT, and was receiving antiplatelet therapy, with anticoagulation recently on hold. Care plan interventions directed staff to use extra caution with transfers and positioning and to avoid activities that could result in injury or falls. Despite this, during the transport in the van involved in the incident, the driver did not secure a lap and shoulder restraint across the resident while she was seated in her wheelchair in the rear of the van. During the return trip from the appointment, the driver reported traveling below the posted speed limit when another vehicle pulled into the van’s path, prompting him to brake and swerve to avoid a collision. The resident’s wheelchair had been locked and secured to the floor, but no lap/shoulder restraint was applied. As a result of the abrupt maneuver, the resident was thrown forward out of the wheelchair, over a folded second-row seat, and came to rest face down and upside down between the folded second-row seat and the back of the driver’s seat, with her head near the floorboards. First responders found the resident unresponsive, pulseless, apneic, and cyanotic from the neck up, with blood from the nose and a few wounds from the fall. EMS documentation described the position as making adequate assessment impossible until she was removed from the van, and the presumed etiology of cardiac arrest was suspected positional asphyxia. Subsequent review of the van and staff interviews showed that the vehicle was equipped with a red lap belt and a shoulder restraint system designed for wheelchair passengers, but the lap belt was found rolled up on the floor and the shoulder belt was present in the rear of the van. A police officer and EMS documentation indicated it was believed the resident did not have a lap belt secured during the accident, and injuries were consistent with being ejected from the wheelchair. The driver stated he had been trained to secure wheelchairs and to use lap/shoulder restraints in a different van model, but reported he had not been taught how to use the lap/shoulder restraints in the van involved in the incident and that he never used them in that vehicle. Other drivers and the Environmental Services Director confirmed that driver training and proficiency testing were conducted using a different van, that there was no documentation of specific training on the incident van’s restraint system, and that manufacturer’s instructions for the lap/shoulder restraints were not available. Facility policies and the driver’s job description required that all passengers wear seatbelts and that residents be secured with restraints during transport, but the actual practice in the incident van did not include consistent use of the lap/shoulder restraints for wheelchair-seated residents, leading to the resident being transported without this protection at the time of the event. The facility’s internal incident report and root cause analysis acknowledged that they were unable to confirm that an over-the-lap or cross-body seat belt had been applied in addition to securing the wheelchair, and that this may have contributed to the resident moving forward in the van compartment during braking. The Fleet Management Program required pre-use safety checks and mandated that drivers ensure all passengers are secured by seat belts before the vehicle is in motion, and the driver’s job description emphasized resident safety and following procedures for securing residents with restraints. However, the Driver Proficiency Test did not specify which vehicle was used and did not include evaluation of securing wheelchair residents with lap/shoulder restraints for each vehicle type. The Facility Assessment Tool also did not identify transportation as a service or drivers as staff, despite the facility operating a bus and two vans for resident transport. These omissions and inconsistencies in training, documentation, and implementation of seatbelt use directly preceded the transport of the resident without a lap/shoulder restraint and the subsequent fatal incident when the van driver swerved and braked. The Immediate Jeopardy began on the day the resident was transported without the use of a lap and shoulder restraint and was identified by the State Agency during the survey. The facility’s own summary of the alleged incident, along with external reports from police, fire, and EMS, consistently documented that the resident was secured in the wheelchair but not with a lap/shoulder belt at the time of the event. The physical inspection of the van confirmed the presence of the restraint equipment that was not in use, and staff interviews revealed a pattern of incomplete, vehicle-specific training and lack of written or manufacturer guidance on the restraint systems. Collectively, these findings show that the facility failed to ensure the environment of transportation was free from accident hazards and failed to provide adequate supervision and implementation of required securement procedures to prevent the resident’s ejection from the wheelchair during an emergency driving maneuver.
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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