Based on interviews, record review, observations, and document review, the facility failed to prevent an accident that caused serious injury during a van with lift transfer due to not following the manufacturer's guidelines for the lift and training for 1 (Resident #199) of 1 resident reviewed for accidents. This deficient practice resulted in Resident #199 sustaining a left ankle fracture on 09/10/2024, and a suspected fracture to the sacrum. The findings are: On 09/17/24 at 11:09 AM, during an interview with [NAME] President of Operations regarding incident he confirmed Certified Nurse Aide #1 (CNA #1) assisted with unloading Resident #199. CNA #1 failed to confirm the lift gate was up and ready for the transfer which caused the fall. CNA #1 was suspended until the end of the facility investigation, then terminated. On 09/17/24 at 11:11 AM, Director of Nursing (DON) interviewed regarding the incident on 09/10/2024 involving Resident #199. When asked what her immediate action was following the incident, she confirmed she assessed Resident #199 then sent the resident to the nearest emergency department for an evaluation and treatment. She confirmed provider and family were notified. On 09/17/24 at 11:31 AM, Resident #199 was interviewed regarding incident. Resident stated, I was just sitting there in the van waiting to be taken back in and all of a sudden I was falling backwards. It happened very quick. My body was all catawampus, and was like a V, my legs came up to my body. Resident confirmed pain level was controlled with current treatment. On 09/17/24 at 02:04 PM, Maintenance Director was interviewed regarding mechanical actions/demonstration of lift on the 2018 van. Staff demonstrated the process of loading and unloading residents in wheelchairs. He demonstrated the warning threshold plate working properly (safety mechanism to warn the gate is not up). During an interview on 09/17/24 at 2:30 PM, CNA #7 stated she returned from assisting the first resident into the building and came back to assist CNA #1 with the last resident (Resident #199). The lift gate was down from the first transfer, and stated as she approached the van, she saw Resident #199 fall from the van in the wheelchair, and then CNA #1 fell out of the van soon after. CNA #7 confirmed she completed re-training on about 09/12/2024. On 09/17/24 at 2:40 PM, the Maintenance Director was interviewed regarding the van transport wheelchair training 01/16/2024. He confirmed CNA #1 was present for the class. Maintenance Director confirmed he attended the re-training for van transfers on 09/12/2024. On 09/17/24 at 02:44 PM, the Administrator was interviewed regarding the incident involving Resident #199. The Administrator confirmed CNA #1 did not follow the manufacturer's guidelines or the training, which CNA #1 last completed on January 16, 2024. On 09/17/24 at 03:27 PM, CNA #1 was interviewed regarding the incident on 9/10/2024. She stated, I assisted [CNA #7] in undoing the floor strap for the other resident. CNA #7 took the other resident inside the building, and I was in the process of undoing the floor strap for Resident #199 and preparing to transfer the resident. I said okay, and then I heard CNA #7 say okay, so I thought that meant she was ready and the lift was up, so I proceeded to push the resident to the edge, then both of us fell and that's when I knew the gate was not up. When asked if she looked to see if the gate was lifted, she stated, I am too short to see over the resident in the wheelchair. When asked about safety mechanism to alert gate is not up, CNA #1 stated, Are you talking about the beeping? It always beeps regardless of if it's up or down. CNA #1 stated, My last transfer training was at least two years ago. When asked if CNA #1 had worked as a transporter before her other roles, she stated, Yes, I used to be a transporter, then I switched to HR [Human Resources] about 6 years ago, but I was filling in doing transports. On 09/17/24 at 12:17 PM, the surveyor reviewed video footage of the incident that happened on 09/10/2024 at approximately 12:30 PM. The video shows the return of the transport van with two residents, CNA #1 and CNA #7. One resident was unloaded from the transport van without incident by CNA #7 and taken inside the facility. The gate remained lowered. CNA #1 was seen holding the wheelchair, facing the resident, both are located at the rear exit. As CNA #7 walked out of the front door, she walked toward the back of the van and noticed CNA #1 was struggling to hold the wheelchair/resident inside the back of the van. CNA #7 approached the van to assist but was unable to prevent the resident from falling out of the van. Resident #199 fell approximately 24 (measured from floor of van to base of the lift lowered). Resident #199's legs spread outward in opposite directions. The resident remained seated inside the wheelchair. CNA #1 also fell out of the back of the van, and partially landed on the left portion of the wheelchair, struck Resident #199's left leg/foot, pressing the resident's foot against the left foot pedal of the wheelchair. This action potentially caused the fracture to the left ankle. Resident #199 also sustained a suspected fracture to the sacrum (low back area). Reviewed the undated, Operator's Manual for the facility's wheelchair lift. Under the section labeled operation notes, vehicle loading and unloading, it read, The platform must be fully raised (at floor level) and the inner roll stop (bridge plate) must be properly positioned when loading or unloading passengers in or out of vehicle. It is the responsibility of the lift attendant to ensure the platform, and the inner roll stop are properly positioned at floor level when loading and unloading passengers. Review of training provided to CNA #1 on van transfers including the most recent dated 01/16/2024. The training acknowledgement was signed, and the signature matches other signatures in CNA #1 employment file. Other attendees of the van transfer training on 01/16/2024 confirmed CNA #1 was present for that training. A requirement for training included each of the transport staff to demonstrate proper loading and unloading techniques with a focus on understanding all safety measures. Transport staff were required to demonstrate proper operation of the transport van equipment to the instructor. Reviewed facility undated policy titled Accidents and Incidents - Investigating and Reporting Policy and the Facility Van/Vehicle Usage, undated policy which was consistent with the facility's actions following the incident on 09/10/2024. The facility completed an in-service for all staff on Abuse/Neglect dated 09/10/2024. On 09/18/24 at 10:49 AM, interviewed [named] Van and Mobility Mechanic that inspected the transport vans following the incident. He confirmed the safety mechanism on the threshold warning plate would not beep when the gate is fully up and engaged. [Named] Van and Mobility Mechanic also confirmed no repairs were needed on the lift or any other portion of the vans at time of inspection (09/16/2024). During an interview on 09/19/24 at 11:10 AM, CNA #6 confirmed the last training regarding van transport was on 09/13/2024, and attendees were required to demonstrate the skills of loading and unloading residents from the transport van via wheelchair, and safety measures. The facility implemented corrective actions which were completed prior to the State Agency's completion of its survey; thus, it was determined to be a Past Noncompliance citation. The facility has implemented the following plan of correction to correct the deficient practice effective 09/11/2024. Facility Plan of Correction: Step #1 Corrective Plan: On 9/10/2024 upon notification of deficient practice, the Administrator/designee immediately disabled the transport van from this incident from all further transports until investigation and review was completed. The transportation aide was not permitted to perform any further transports or transfers until corrective measures were completed and she was suspended from employment pending investigation process. Step #2 Identification of others with the potential of being affected: On 9/10/2024 the DON/Designee determined, through medical record review and transportation data for the last two weeks, that five residents had to potential to be affected and assessed all residents identified to ensure no injuries related to transportation had occurred. Step #3 To ensure deficient practice does not reoccur: On 9/10/2024, the Administrator made alternate arrangements for all resident transports until completion of transportation aide in-services with return demonstration could be completed. The maintenance director assisted in ensuring this staff education was completed. Both facility vans were placed in no transport mode until a thorough van/equipment inspection could be completed. Step #4 Monitoring: Administrator/designee will monitor loading and unloading of residents to facility vans for transport 3 times a week times 4 weeks minimally or until compliance is achieved. Findings will be documented on a monitoring log. Any negative findings will be corrected immediately, and Administrator/Designee notified. Step #5 QA Administrator/designee will present all findings to the monthly QA committee for further review and recommendations. The facility alleged compliance on 09/13/2024 The facility has implemented their Quality Assurance and Performance Improvement plan, and all steps have been completed, or if ongoing, has been initiated. The following are the goals listed with progress: 1. All staff members who will be driving the van will have a valid driver's license and approved driving record. Completed 09/11/2024 2. All staff members who will be driving the van or assisting during transport will be trained per manufacturer's guidelines/operator training videos and facility checklist. This will include instruction on lift operation and use of a sure-lock restraint system. Completed on 09/13/2024 3-service will be initiated when an incident occurs that involves the van. 4. The van must be taken out of service until deemed safe to use by [named] Van & Mobility of named city. All incidents/accidents involving the van will immediately be reported to the administrator/DON or designee. Incidents/accidents involving the van will be investigated and an incident report completed. Completed: 09/16/2024 and ongoing for continued monitoring. 5. Transports from facility will be monitored by a trained staff member 3 x weekly for 4 weeks, or until compliance is achieved. The above plan will be presented to the QAA committee, and any negative findings will be corrected immediately and reported to the QAA committee. Completed: This plan was starting immediately, but the facility chose to make alternative transport arrangements for all residents and halt all van transfers until they received the documentation from the van inspection which was 9/16/24, and the plan is ongoing. 6. Maintenance Inspection: Regional maintenance consultant will review van maintenance plan with maintenance director immediately and quarterly thereafter. Completed: 09/12/2024 and ongoing. 7. The van driver will perform a pre-transport documented inspection daily, prior to the first transport. 09/11/2024 and ongoing. 8. The facility will maintain a current list of employees who have been trained to drive the van and assist with transportation along with supporting documentation regarding training. Completed:09/13/2024 and ongoing. 9. Any transport driver found not following the appropriate transport policies will be immediately taken off transportation duty and disciplined up to and including termination. The staff member involved in the incident on 09/10/2024 was terminated after the facility's completed investigation. Completed: 09/11/2024 and ongoing. The facility implemented a plan for retraining all transport staff which was completed on several different dates, but the final transport staff member completed the training on 09/13/2024. The staff watched the manufacturer training video linked below: https://youtube.com/watch?v=vDLdUXcotEc&si=LgpoAUyOrtwuHRJV The transport staff completed training along with demonstration of the skills of loading and unloading a resident in a wheelchair. Training also included safety measures for safe transportation of residents. This training will be ongoing.