Improperly Secured Van Seat Causes Resident Injury During Transport
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment remained as free from accident hazards as possible and to provide adequate supervision and assistance to prevent accidents during van transport. A male resident with multiple serious medical diagnoses, including CHF, mild dementia, ESRD requiring dialysis, atrial fibrillation, prior cerebral infarction, hypertension, and severe protein-calorie malnutrition, was being transported by a transport aide (TA) to a dialysis center. The resident, who was ambulatory with a walker and had moderate cognitive impairment (BIMS 10/15), was seated in a high-back chair in the facility van rather than in a wheelchair. The chair had been added to the van to accommodate additional riders and was attached to floor rails intended to secure it in place. On the day of the incident, the activities director (AD) accompanied the TA and observed that one of the front legs of the added chair did not appear to be on the track properly. The AD told the TA that the chair was not right and instructed her to check it; the TA then reattached the chair to the floor railing. The AD reported that she checked the chair again before the resident sat in it and believed it was sturdy and solid. The TA stated she had been trained on wheelchair security in the van but had not been trained on how to install and secure the removable seats, and that this was the only time she had ever put a seat in the van. Despite this, she installed the seat that morning and used it for the resident’s transport. While the van was in traffic at a stop sign in a local community, the TA made a low-speed left turn. At that point, the chair tipped sideways, and the resident, who was belted into the chair, fell over and struck the van door with his right shoulder and side. The TA and AD heard a thud and found the resident leaning over while still strapped to the tipped chair. The TA pulled the van over, assisted the resident up, and transferred him to a different chair. The resident reported right shoulder pain but initially had no visible injuries and could move his shoulder. A same-day x-ray of the right shoulder was read as negative for fracture; however, a later CT scan of the right upper extremity showed an acute, mildly comminuted and minimally displaced fracture of the right distal clavicle and an acute, nondisplaced right anterior 2nd rib fracture. The incident was determined to have resulted from the van seat not being properly secured to the floor track, with subsequent inspection revealing that the safety bar had not fully engaged or seated properly within the groove intended to prevent the latch from loosening and that the handle was difficult to manipulate into the fully secured position. Additional documentation and interviews showed that the facility had a Daily Vehicle Pre-Trip/Post-Trip Inspection Checklist, which on the day of the incident noted only windshield chips and did not identify any issues with seats or restraints. The Weekly Vehicle Inspection Report included checks of seats, seat belts, and wheelchair tie-downs, and the Employee Auto Training Handbook required drivers to ensure the vehicle was in safe operating condition and to correct any unsafe conditions before use. However, the TA reported she was not trained on installing or securing the removable seats, and the Administrator later stated that the TA should not have been responsible for putting seats in or out of the van, indicating that this task should have been assigned to maintenance staff. The combination of an improperly secured removable seat, incomplete staff training on seat installation, and reliance on a pre-trip inspection that did not detect the hazard led directly to the resident’s fall inside the van and subsequent fractures. The resident’s account during interviews was consistent with the documented events: he stated that the seat in the van was not latched well, that when the driver turned, the chair tipped, and he fell against the van door, injuring his shoulder and hitting his head. He reported ongoing shoulder pain until the CT scan identified the fractures. Dialysis center documentation confirmed that on arrival he complained of right shoulder pain from a fall in the van, had no swelling noted, and received PRN acetaminophen. The facility’s own investigation concluded that the incident occurred when the van seat/chair tipped sideways during a low-speed left turn from a stop sign, causing the resident to strike the van door, and that the safety bar on the seat had not fully engaged in the floor track, allowing the latch mechanism to loosen and the seat to tip during normal vehicle operation. The facility’s investigation also identified that the van seat had been repositioned over the weekend to accommodate additional residents for a community parade, and that the latch hardware on the seats was stiff, requiring lubrication. The Maintenance Supervisor and Administrator later found that the red pin at the bottom of the chair was hard to push down to properly secure the chair, and that the handle was difficult to manipulate into the fully locked position. Despite these mechanical issues and the lack of specific training for the TA on seat installation, the seat was used for resident transport. This sequence of events—repositioning and reinstalling a removable seat with a stiff and difficult-to-secure latch, incomplete staff training on seat installation, failure to detect the improperly engaged safety bar before transport, and subsequent tipping of the seat during a routine turn—constituted the failure to maintain a hazard-free transport environment and to provide adequate supervision and assistance to prevent the resident’s accident and injuries.
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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