§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
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Observations:
Based on review of facility policy and documentation, staff and resident interviews it was determined that the facility failed to protect residents from neglect which resulted in actual harm of multi-system trauma for one of three residents (Resident R1) and transfer to a trauma center hospital.
Findings include:
Review of facility policy "Abuse, Prevention of Resident Abuse, Neglect, Mental Abuse, Reports of Theft, and Misappropriation of Property" dated 8/18/25, indicated the facility will provide a safe and secure environment for all residents and will protect a resident's right to be free from any form of abuse, mental abuse, neglect, reports of theft, and misappropriation of resident property.
Review of the facility policy "Transportation-Competencies and Monitoring" dated 8/18/25, indicated all drivers will perform and pass competencies in the following areas: Q-Straint Wheelchair Securement (straps and buckle system that secures wheelchair in wheelchair van), van lift operation, driver responsibilities while escorting a resident, and safe operation of vehicle.
Review of the clinical record indicated Resident R1 was admitted to the facility on 10/12/24.
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/15/26, indicated diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Section C0500 Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of 15, cognitively intact.
Review of Resident R1's progress note dated 1/20/26, at 2:37 p.m. indicated resident was on the way to an appointment in the wheelchair van. Per resident's statement the van was taking a left-hand turn when the wheelchair tipped over and resident landed on their right side. Resident believes they hit their head on the door of the wheelchair van. Resident was assisted out of the van and back to the bed. Resident complained of significant pain to the right shoulder, right hip, had a small hematoma (a localized collection of clotted or partially clotted blood outside blood vessels, caused by damaged vessel walls from trauma) above the right ear, and hematoma on the right ear. Unable to assess right hip and right shoulder for bruising while in bed due to pain with movement trying to remove clothing. Resident is on Lovenox (blood thinner). Orders received to transfer to the emergency room. Brother present and made aware of transfer orders.
Review of the hospital documentation dated 1/20/26, indicated resident was in a wheelchair van and resident stated they were not secure in the chair. The chair was secure in the van. The wheelchair went around the bend, and it tipped and collapsed on the resident making the resident fall. Complaints of right shoulder and right hip pain that struck the side of the van. Resident also struck their head.
Injuries:
1. Non-displaced right transverse process fracture of the seventh cervical vertebra of the spine (C7).
2. Acute right transverse process fracture of the second thoracic vertebra of the spine (T2).
3. Fractures of the first, second, third, and fourth right ribs.
4. Fracture of right clavicle (collar bone) with questionable extension into the joint.
5. Non-displaced fracture of the posterior inferior right pubic ramus (part of lower pelvic bone).
6. Acute comminuted (severe injury where a bone breaks into three or more pieces) fracture of the anterior right hip acetabulum (socket of hip).
7. Questionable fracture of right lateral sacrum (base of the spine that forms the back wall of the pelvis).
Emergency room physician at local hospital discussed resident's case with Trauma Hospital physician at another hospital reporting multi-system trauma from fall in a wheelchair van while going around a bend. The trauma level hospital accepted the care of resident and ordered transfer for further treatment.
Review of facility provided documentation dated 1/20/26, indicated Incident: resident fall with injury during wheelchair van transport due to failure to apply passenger seatbelt.
Review of Driver Employee E1's signed witness statement dated 1/20/26, indicated they turned left in a wide and slow turn, the wheelchair collapsed and went to the right. The resident fell off wheelchair onto the floor of the van. The wheelchair seemed flimsy when the driver strapped the lower bars in at all four points.
Review of Resident R1's signed witness statement dated 1/20/26, indicated the driver did not fasten a belt around their chest.
Interview with Maintenance Manager Employee E2, on 2/11/26, at 11:31 a.m. indicated the Q-Straint system is a five-point system, four connect to the actual wheelchair and then there is a chest lap harness almost like a regular seat belt, as the fifth point. The following day I examined the van and all the parts and belts were intact and functioning. The resident said that the final seatbelt strap was not connected correctly, and if it had been resident would not have suffered a fall.
Interview on 2/11/26, at 1:45 p.m. Resident R1 indicated the wheelchair was strapped into the floor but Driver Employee E1 never put the chest lap harness on. When we went around the bend in the van, the chair tipped over and resident fell to the wheelchair van's floor on the right side.
Interview on 2/11/26, at 11:45 a.m. the Nursing Home Administrator indicated the Driver Employee E1 was terminated for neglecting to use the Q-Straint appropriately at all five points as required.
During an interview on 2/11/26, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to protect Resident R1 from neglect when staff failed to properly secure resident in wheelchair van resulting in actual harm of multi-system trauma for one of three residents (Resident R1) and transfer to a trauma center hospital.
28 Pa. Code: 201.14(a) Responsibility of licensee
28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 03/04/2026
R1 was immediately assessed for injuries following the incident and received appropriate medical evaluation and treatment. E1 was suspended pending investigation and ultimately terminated. All bus trips were cancelled or rescheduled with outside transport during the investigation.
Going forward, all new drivers will receive education and training on wheelchair transportation and safety to include: proper use of four point wheelchair tie downs; mandatory use of passenger lap and shoulder seatbelt; and immediately calling 911 if a resident is injured in the vehicle. Additionally, a wheelchair securement checklist is now required for every transport involving a wheelchair user. Drivers must verbally confirm and visually verify that: the wheelchair is fully secured and the passenger seatbelt is applied correctly. Failure to follow securement procedures will result in progressive disciplinary action per facility policy. Transportation policies and procedures were revised to clearly state that transport may not begin unless both wheelchair and passenger restraints are in place. The supervisor will conduct weekly unannounced audits of the driver providing wheelchair transport and document their audit. The maintenance supervisor will also ensure the Q-straint Wheelchair Securement Checklists are completed and signed off on for every wheelchair transportation. The maintenance supervisor will complete competencies at least every 3 months on the driver in the following areas: Q-straint wheelchair securement, van lift operation, driver responsibilities while escorting a resident, and safer operation of the vehicle.
The maintenance manager and director were educated on the new process on 1/28/2026 by the Administrator.
AAE Consulting Services will conduct a Directed In-Service on 2/27/2026 for F689 Accidents/Hazards/Supervision for all staff including agency. A copy of the presentation will be available for any staff member unable to attend the in-person training.
Supervisory staff will conduct random observational audits of wheelchair transports at least monthly. Completed wheelchair securement checklists will be reviewed weekly by management. Any identified noncompliance will result in immediate retraining and documentation. Transportation safety will be reviewed during ongoing staff meetings and annual competency evaluations. Results of audits will be tracked and reviewed as part of the facility's Quality Assurance and Performance Improvement (QAPI) program.
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