Otterbein Middletown

Review of the wheelchair vans undated manufacture instructions revealed attach the four tie- down hooks to the solid frame members or weldments near seat level.

Ensure the tie downs are fixed at approximately 45 degrees. Do not attach the hooks to wheels, plastic or removable parts of the wheelchair.

Review of the facility's undated guidelines and regulations for a minibus carrier, revealed there should always be a total of four anchor points with two in the front of the wheelchair and two in the back of the wheelchair.As a result of the incident, the facility took the following actions to correct the deficient practice by 10/06/25: On 09/24/25, Resident #14 was transported to the hospital for assessment.On 09/25/25, Resident #14 was assessed by PA #500 and psychiatric NP #600 with no new orders.On 09/25/25, the facility's QA committee held ad hoc meeting regarding transportation.

Transportation education and demonstrations were scheduled for 09/29/25 and the transportation checklist was reviewed.

The facility also developed a transportation audit.On 09/25/25, all CNAs were provided with education on securing wheelchairs in the wheelchair van by CNA #58.On 09/26/25, the Administrator completed interviews of the residents that had utilized the facility transportation with no findings.On 09/29/25, all CNAs were educated in person by Corporate Maintenance Director #700 on wheelchair transportation and all staff demonstrated their competencies on the bus and transport van checklist.On 10/06/26, transportation audits were initiated by the Administrator, CNA #58, the DON or designee on all facility transportations to ensure residents were strapped in correctly, residents had the correct durable medical equipment and to ensure staff were following the transportation checklist.

The Audits will be completed for four weeks.

This deficiency represents non-compliance investigated under Complaint Number 2634560 and 2629140.

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