Based on record review and interview, it was determined that for one (R1) out of six residents reviewed for accident hazards and falls, the facility failed to ensure R1's environment was free from accident hazards as possible. On 6/28/23, while being driven back to the facility in a borrowed transport van from another facility, an accident occurred which resulted in R1 sustaining multiple fractures. The unsafe facility transport caused R1 harm. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 7/5/23. Findings included: R1's record revealed: 9/8/21 - R1 was admitted to the facility with diagnoses including, but not limited to, cancer and difficulty in walking. 5/31/23 - A significant change MDS assessment documented that R1 was cognitively intact with a BIMS of 15. 6/28/23 - The facility's incident report and investigation revealed that after attending a social outing, R1 was being driven back to the facility when the transport van driver tapped the brake causing R1's wheelchair to propel forward and R1 to slide out of the wheelchair onto the van's floor. R1 was returned to the facility where 911 was called and fire company EMS (Emergency Medical Services) transported R1 to the hospital. 6/28/23 11:08 AM - Per C1's (hospital Forensic Nurse Examiner) notes, R1 arrived at the hospital after a motor vehicle collision with complaints of right and left leg pain. Reportedly R1 stated, I fell out of my wheelchair when the bus stopped short. 6/28/23 1:17 PM - The hospital record documented, [R1] was on a transportation van when it came to a sudden stop causing [R1] to fall out of [R1's] wheelchair striking [R1's] head and bilateral lower extremities. The record documented findings of a frontal contusion and abrasion no active bleeding left lower extremity medial aspect of calf large laceration with exposed adipose tissue measuring approximately 15 cm by 10 cm. [R1's] right lower extremity with 2 linear lacerations to the lateral aspect of [R1's] lower leg approximately 10 cm in length bleeding noted dressing applied .[R1] is complaining of significant pain to [R1's] left lower extremity with any movement. 6/28/23 3:00 PM - R1's facility progress note documented, At around 10:20 (AM) received a call from the receptionist that 'a resident fell in the van outside'. Rushed to the assisted living entrance and the transportation van pulled up and noticed [R1] lying on the foot bed of the van supine in front of her wheelchair. [R1] verbalized that she slid from the wheelchair during the van transport and that her legs hurt. Denies any LOC (loss of consciousness), or head injury. [R1] was awake and oriented to person, place, time and situation. Laceration noted laterally on bilateral shins. Scant amount of blood noted, no active bleeding noted. Nurse Practitioner [E30] in the building made aware, ordered to ok to send [R1] to the hospital. Emergency Service called and [R1] picked up by . fire company EMS (Emergency Medical Service). [R1's family member] . made aware of the incident and verbalized that she would meet [R1] at the hospital. 6/28/23 11:34 PM - Per the hospital record, R1 was transferred to another hospital after the previous facility noted bilateral open tibia-fibula fractures that occurred earlier that day when R1 was being transported in a wheelchair and not strapped in causing [R1] to fall out of the wheelchair. The hospital record documented a need for surgical repair. 6/28/23 - The facility's documented immediate actions in response to R1's transport accident included the following: - canceled all other appointments and resident transport for the day; - suspension of the driver [E18] because the preliminary investigation indicated that [E18] did not follow safety protocol .; - observation of the van and wheelchair immediately after the incident revealed that the shoulder strap was not fastened; - training initiated and completed by the plant manager [E21] on proper and safe medical transport; and - initiation of an investigation of the incident. 6/28/23 - The facility's in-service training documentation included the following: - Loading and Unloading Non-Ambulatory Wheelchair Passenger Policy (operating the wheelchair lift, positioning the wheelchair in the vehicle, attaching the two rear securement straps, attaching the two front securement straps, attaching the lap belt, attaching the shoulder belt); - Wheelchair Securement Checklist; and - Training (must include and frequency). The in-service training was completed on the same day, 6/28/23, of R1's accident. 6/29/23 - The hospital records documented that R1 was . going to the operating room for ORIF bilateral periprosthetic proximal tibia fractures today. 7/5/23 - R1 was readmitted to the facility from the hospital. 7/5/23 - The facility's documented plan of correction as a result of the investigation was: - the van driver [E18] was terminated; - root cause analysis - was determined to be related to driver's [E18] negligence by breaching his duty of care to the resident by not applying a restraint device when it was ordinary, prudent and reasonable. This action resulted in the resident sliding out of the wheelchair when the transportation van slowed down; - care plan changes - residents care plan was updated to include safe resident transport. Interventions for this goal was to have resident properly fastened in the wheelchair transportation vehicle; - systemic changes - trained drivers with best practices for loading and unloading non-ambulatory wheelchair passengers to safety. Specifically, all drivers returned demonstration of attaching the shoulder belt. Before each transport the driver must utilize wheelchair securement checklist to ensure residents are secured in transport vehicle. 2/26/24 10:23 AM - During an interview with E1 (DON, interim NHA), with E2 (ADON) and E4 (Corporate Clinical Specialist) present, On 6/28/23, we received a call from the front desk asking if nurses could come to the parking lot STAT. We went outside and I [E1] saw [R1] sitting in the van on the floor, the wheelchair was behind [R1] and [R1] was half lying and half sitting, and both legs were crooked and bleeding. I immediately called 911 and we tried to stop the bleeding. R1 was asked if she was in any pain and R1 denied pain. R1 did say that the van floor was hard on her back. I noticed that the wheelchair was stuck In the van and that R1 was not strapped in. I immediately asked the driver [E18] if he strapped [R1] in, he said that he did not and that he didn't know why he did not. I called her daughter . We did vital signs which were normal and wrapped her legs to stop the bleeding. The fire company was here quickly - they got here before the paramedics. 2/26/24 2:53 PM - During a follow-up interview with E1, with E2 and E4 present, the plan of correction was initiated on 6/28/23 and completed on 7/5/23. 2/26/24 at 2:55 PM - Based on the Surveyor's review of the facility's thorough investigation, documented response, completion of audits from 7/7/23 to 11/24/23, staff interviews and no further transportation incidents, R1's accident was determined to be past non-compliance harm. 2/26/24 3:15 PM - Findings were reviewed at the exit conference with E1, E2 and E4.