SANTA MONICA, CA - Ocean Park Healthcare faced federal safety citations after inspectors observed staff transporting a cognitively impaired resident in an unsafe manner that could have resulted in serious injury.
Dangerous Transport Practices Documented
During a May 2025 inspection, federal surveyors observed a certified nursing assistant pushing a resident in a geri chair with the resident's feet dragging on the floor and head partially unsupported. The incident involved a resident with cognitive impairment, hypertension, anxiety, and major depressive disorder who required assistance with all daily living activities.
The observation occurred in the evening when the CNA was moving the resident in the specialized mobility chair. Inspectors noted the resident's feet were in contact with the floor during transport, creating immediate safety risks.
Staff Acknowledged Safety Concerns
When questioned about the unsafe positioning, the CNA admitted the resident's feet were dragging and the head was not properly supported. "Resident 25's feet were dragging on the floor and Resident 25's head was not comfortable, not fully resting on the chair on one side," the staff member stated according to the inspection report.
The CNA recognized the need for immediate correction, stating she would reposition the resident because "Resident 25's position was not good and Resident 25 may get hurt and the feet may get swollen."
Medical Risks of Improper Positioning
Feet dragging during wheelchair transport creates multiple serious health risks. Contact between feet and flooring can cause abrasions, cuts, or fractures if the foot becomes caught or twisted. For residents with circulation issues or diabetes, even minor foot injuries can lead to infections or non-healing wounds.
The improper head positioning observed poses additional concerns. When the head and neck lack proper support during transport, residents can experience muscle strain, breathing difficulties, or risk of choking, especially those with swallowing disorders.
Cognitive impairment compounds these risks since affected residents may not recognize dangerous positioning or be able to alert staff to discomfort or injury.
Facility Standards Violated
The facility's Director of Nursing confirmed that proper positioning protocols require residents to be repositioned every two hours and as needed when using geri chairs. "The resident's feet should be completely off the ground, resident should be propped up, straight alignment and head of the resident resting on the back of the chair for comfort and to prevent resident getting caught up in the geri chair and getting injured," the DON explained.
Ocean Park Healthcare's own safety policy emphasizes making the environment "as free from accident hazards as possible" and identifies "resident safety and supervision and assistance to prevent accidents" as facility-wide priorities.
Industry Standards for Safe Transport
Professional nursing home standards require staff to ensure wheelchairs and geri chairs are properly adjusted for each resident's physical needs. Footrests must be positioned to support feet completely off the ground, preventing dragging or contact with surfaces during movement.
Head and neck support systems should maintain proper spinal alignment while preventing the head from falling forward or to the side during transport. These positioning requirements become critical for residents with cognitive impairment who may not maintain proper posture independently.
Federal Oversight Response
The Centers for Medicare & Medicaid Services classified this as a minimal harm violation affecting few residents. However, federal regulations require nursing homes to maintain accident-free environments and provide adequate supervision to prevent injuries.
The citation falls under federal tag F689, which mandates that nursing facilities ensure areas remain free from accident hazards while providing appropriate supervision to prevent accidents.
Consequences for Vulnerable Populations
Residents with cognitive impairment depend entirely on staff to maintain their safety during transport and positioning. When basic safety protocols are not followed, these vulnerable individuals face increased risks of preventable injuries that could result in hospitalization or permanent complications.
The incident highlights the importance of consistent staff training on proper mobility equipment use and the need for ongoing supervision to ensure safety protocols are maintained throughout all shifts.
Federal inspectors will monitor Ocean Park Healthcare's corrective actions to ensure proper transport procedures are implemented and consistently followed for all residents requiring mobility assistance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Santa Monica Conv Ctr I from 2025-05-04 including all violations, facility responses, and corrective action plans.
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