**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #41's Minimum Data Set (MDS) dated [DATE], listed diagnosis of Anemia, Hypertension and Non-Alzheimer's Dementia. The MDS listed a BIMS score of 00, indicating severe cognitive impairment. The MDS revealed Resident #41's self-performance as total dependence of 2 people for transfers. Through the lookback period, Resident #41 didn't walk in their room or in the corridor. The Care Plan problem dated [DATE] documented that Resident #41 was at risk of injury from a fall related to impaired mobility, advanced dementia, history of hemorrhagic stroke, and dependent on staff for ADLs. The problem included the intervention dated [DATE] to direct staff to provide assist of two with Hoyer (mechanical lift) for all transfers. Resident #41's Vital Statistics dated [DATE] documented a weight of 119.6 pounds. The Sling and Harness Guide dated 8/21 indicated a sizing guide for most slings indicated a person weighing between 75 to 125 pounds should use a small sling (red in color) during a mechanical lift transfer. The Sling and Harness Guide included the sizing guide as the following - X-small 49-75 pounds white - Small 75-125 lbs. red - Medium 125- 175 lbs. yellow - Large 174 - 250 lbs. green - X-Large 250 - 400 lbs. blue - XX Large 400-600 lbs. orange The Interdisciplinary Note dated [DATE] recorded that a C.N.A. transferred Resident #41 by herself with Hoyer. One of the straps was not strapped correctly, Resident #41 slid out of the Hoyer and hit her head. Resident #41 received an abrasion of one centimeter (cm) long from her fall, on the back of her head. During an observation on [DATE] at 8:33 AM Resident # 41 transferred from her bed to a wheelchair with a mechanical lift by Staff E, C.N.A., and Staff F, Registered Nurse (RN). The sling under Resident #41 had gray loops on the top and pink on the bottom with purple binding. The label on the sling was worn, faded, illegible, and fraying. Both staffs stated they should always use two staff members to transfer a resident with a Hoyer lift. During an observation on [DATE] at 1:40 PM Staff S, C.N.A., and Staff E, provided Resident #41 with total assist in a transfer from her wheelchair to her bed in the mechanical lift. The staff put Gray loops on top and pink loops on the bottom for the straps to complete the transfer. The binding to the sling was purple. During an observation on [DATE] at 4:30 PM Resident #41 sat in a wheelchair in the dining area with a mechanical lift sling beneath her with a green binding on the edges of a blue sling. During an interview on [DATE] at 1:40 PM Staff E said they decided which sling to use by the residents' weight and Resident # 41 should use a medium sling. Staff E reported that she knew the size of the sling to be a medium just by the size of it. During an interview on [DATE] at 1:40 PM Staff S stated the staff got trained on the mechanical lifts in the unit they worked but the lifts were all very similar. Staff S didn't know for sure how to determine what size sling the resident should use. Staff S reported that the slings were in the residents' room and additional slings were stored in the utility closets. During an interview on [DATE] at 2:03 PM Staff E stated she thought they used a shower sling when they transferred Resident #41 for the surveyor to observe. The tag on the sling faded making it difficult to know the information for that sling. Staff E explained that the slings could be interchanged with the different mechanical lifts in the building. During an interview on [DATE] at 10:31 AM Staff V, LPN, remarked that she did recall the incident when Resident #41 fell out of the Hoyer. Staff Y, Temporary Nurse Aide (TNA), came out of Resident #41's room and got her right after the incident happened. Resident #41 was on the floor and the mechanical lift was in the up position with one of the straps not hooked to the Hoyer. The facility policy indicated that two people were to assist for all mechanical lifts. The staff should never use a mechanical lift alone and they should always have someone with them for the transfer. Staff V remarked that she believed the check off list contained that information for training new employees. The slings could be used for different Hoyer's, but Staff V didn't know for sure if they were interchangeable. Staff V explained that it depended on what they were doing with the resident, such as helping to use the toilet or transferring from their bed to wheelchair. The facility had some slings that criss crossed under the legs and some full body slings. The slings that didn't criss cross the staff used them for going to the bathroom. It depends on how many hooks there were on the lift. The facility had Hoyer's with six hooks and some with 4 hooks. Staff V denied remembering which type of Hoyer the TNA used at the time of the fall. During an interview on [DATE] at 11:00 AM Staff W, RN, reported being the DON at the time of Resident #41's fall from the mechanical lift on [DATE]. Staff W explained that the facility policy required the use of two people for transfers with the mechanical lift. The new staff received training at the time of hire of six days of orientation. The new staff then do one-on-one (1:1) training with how to transfer a resident. After completing the training, they need to sign off the orientation checklist. The employee's documentation of education should be in the employee file. The new C.N.A. were shown by another C.N.A. or a nurse on how to use gait belt, a Hoyer lift, and a standing mechanical lift (EZ stand). The hoyers didn't have much of a difference, the facility purchased enough slings to have one for each resident, the facility should have adequate equipment. The facility did disciplinary action and education right on the spot at the time of the fall for Resident #41. During an interview on [DATE] at 11:05 AM Staff X, RN, recalled that on [DATE] CNA came to get the nurse for Resident #41 she was visibly upset so she went with the CNA and the nurse. We walked in the resident room and the resident was on the floor and the Hoyer was up in the air and the sling was half attached to the mechanical lift. Resident had some blood from her head. The training is provided on orientation for mechanical lift. I am pretty sure they go over the sizes but can look at the packet to see what it covers. There should always be 2 assists with mechanical lift. There are like 3 sizes of slings and it is based on the resident. They cannot use the slings from neighborhood to neighborhood. During an interview on [DATE] at 12:06 PM Staff T, RN, added that the facility had a TNA which was a C.N.A. in training, she was transferring the resident by herself, and she did not ask anyone else for help. Resident #41 was very shaken up when she entered the room after the fall. The mechanical lift was in the highest spot with one strap of the sling disconnected from the Hoyer. Generally, therapy helped to assess which sling to use for the resident. Each resident had their own sling in their room. The C.N.A.'s just knew what sling to use, and the Resident's Care Plan should have which sling to use. The slings didn't have a label to tell the staff which one to use. Staff T reported that she received training when she got hired on how to use the mechanical lifts. The Administration staff just provided a review on how to correctly put the loops on the hooks on the Hoyer, how to correctly position the Hoyer, and then maneuver the resident. Staff T reported that they didn't go through the different types or sizes of the slings. The Nurse Manager or the DON trained Staff T regarding the use of the mechanical lifts. The facility had a policy that there should always be two staff when completing a mechanical lift transfer. Staff T explained that the slings were typically right in the rooms and if someone needed to go get one, they could go to the central supply. Staff T remarked that there was no way they could label them for the different residents. During an interview on [DATE] at 1:37 PM Staff D, C.N.A. said that she worked at the facility for two to three weeks. Staff D commented that for orientation the education or training she received in the resident rooms included observation while the staff did the transfers with the mechanical lifts. The staff would tell Staff D the little key things about the transfer. Staff D added the she didn't know for sure about the different slings or the different sizes of slings for the different residents. Staff D expressed that she just made sure that the sling fit by comparing it to the other one used by the resident. Staff D reported that there had to be a way to size them but she didn't know for sure what it is. Staff D explained that the other staff didn't show her that yet. Staff D reported she completed her orientation. Staff D add that she filled out a checklist and then her trainer would initial it. From there she signed it and took it to the scheduler or the DON. The mechanical lifts should always have two staff in the room when using the lift to transfer a resident. During an interview on [DATE] at 3:36 PM the DON stated the weight guide in the user manual determined the size of the sling. The staff determined which sling to use from the size of the resident by their weight and which color sling should be used with a mechanical lift. It should be on their CNA care sheet what size and color sling the resident should use for a transfer. The CNA should reference the care cards in the charting office. The Orientation Checklist included training for the mechanical lift and their mentor should sign off on it after completion of their training. The employee file should have the completed training checklist. The DON explained that she would expect the staff to have the orientation checklist on the use of a Hoyer before working on the floor with the residents. The DON expected the staff to use a mechanical lift to have two staff and use the right sling based on the right size for the resident. Staff Y employee file lacked training documentation related to the education on how to use the mechanical lift. Staff Y's employee file revealed a disciplinary action dated [DATE] titled First Warning - Written with nature of the violation listed as an improper transfer of a resident. The summary of conversation stated: must use an assist of two staff for all mechanical lift transfers. May not change transfer status for the ease of the employee. May not ever transfer a mechanical lift independently. The Owner's Manual for the Hoyer lift dated 2017 on Page 5 indicated the following information a. Untrained operators could cause injury or be injured. b. Permit only trained personnel to operate the lift. c. Improper operation could cause injury. Operate the lift only as described in the manual. d. Visibly inspect the sling before each use to ensure the sling was the correct type, size, and design to handle lifting. e. Ensure the sling was not damage, torn worn, discolored, or past its useful life; that the slings straps were correctly attached to the spreader bar. f. Page 17 recorded important in all capital letters with red ink that the wrong sling size could allow patients to fall out. Refer to the separate sling user guide for selecting, attaching, and using lift with slings. The Limited Lift Program Skills Checklist - Hoyer/Porta Lift dated [DATE] directed staff to identify the correct lift and/or sling for the resident. The undated EZ stand and Mechanical Lift Policy directed staff to provide all resident care in a safe, appropriate, and timely manner in accordance with the individual resident's care plan 5. Resident #16's MDS dated [DATE], listed a diagnoses of non-traumatic brain dysfunction and dementia. The MDS reflected a BIMS score of 4, indicating severe cognitive impairment. The MDS documented total dependence on 2 people for transfers. The Care Plan for Resident # 16 dated [DATE], read to use an assist of 2 for all Hoyer transfers. Resident # 16's Vital Stats dated [DATE], reflected a weight of 205.2 pounds on [DATE]. The undated Care Card, directed that Resident #16 required an assist of two staff and a Hoyer lift for transfers. On [DATE] at 7:38 AM, Staff C, and Staff D, utilized the EZ Way Smart Lift with the black edged sling to assist Resident #16 into his Broda chair. On [DATE] at 2:00 PM, the EZ full body lift sling sat in Resident #16's Broda chair, the tag on the sling appeared worn, faded, and illegible. On [DATE] at 7:25 AM, Resident # 16 sat up in the Broda chair with a blue full body sling with yellow edges under him. The EZ Way Smart Lift Operator's Instructions revised on [DATE] on the size chart on page 20, directed: For the weight range of 190-320 pounds, use the large burgundy sling. For the weight range of 280 to 420 pounds, use the X-large green sling. For the weight range of 400-600 pounds, use the XX-Large black sling. The State Agency informed the facility of the Immediate Jeopardy (IJ) on [DATE] at 9:59 AM. The facility staff removed the Immediate Jeopardy on [DATE] through the following actions: a. The facility removed the IJ by identifying what size sling should be assigned to each resident that used a Hoyer transfer according to the sizing information provided by the manufacture. The C.N.A care sheets were updated with the sling color. b. The staff removed the Tollos Hoyer lift from service and all slings that went with it. The staff would only use the EZ way Hoyer's and slings. Additional EZway slings arrived on [DATE] and distributed to the correct resident. c. The orientation skills checklist for training staff on proper Hoyer transfers had been updated. On [DATE] all staff in the building received education on the lift transfer procedures. d. Each new hire would review the Hoyer checklist and demonstrate competency in transferring with a Hoyer before starting on the floor. The Nurse Managers would perform audits on the slings and the lift transfer procedures twice per week on each resident that used a Hoyer transfer with a random employee for 90 days. The scope lowered from K to E at the time of the survey after ensuring the facility implemented education, their policy, and procedure. Based on observations, clinical record reviews, and staff interviews, the facility failed to provide adequate nursing supervision for five of five residents reviewed (Resident #103, #25, #2, #41, and #16) to prevent a fall with injury. Resident #103 fell on [DATE], he had a severely impaired cognition level. No staff observed Resident #103's fall and took his word that he didn't hit his head. That night Resident #103 continued to complain of a headache all night. On [DATE], Resident #103 fell again documentation determined a skin tear to his right elbow with a bump on his head. At that time Resident #103 refused to go to the Emergency Room. On [DATE], his temperature went up and Resident #103 noted to have increased confusion. The family received notice and Resident #103 transferred to the emergency room on [DATE]. The Computed Technology (CT) Scan on [DATE] showed a large subdural hematoma. On [DATE], after Resident #103's unwitnessed fall, Resident #103 expired the hospital. During an appointment to the dentist, Resident #25 left in the facility van drove by a facility staff member. In the ride, Resident #25's wheelchair fell over sideways with her in it. An ambulance was called and the resident transported to the emergency room (ER). At the Emergency Room, radiology reports indicated a small brain bleed with a fractured (broken) clavicle (collar bone). Through additional clinical reviews, Resident #2 noted to have a history with falls and required staff assistance with transfer. On [DATE], Resident #2 noted to be on her bathroom floor complaining of pain to her fingers, left hip pain, and shortness of breath. After transferring to the hospital by ambulance, Resident #2 admitted to the hospital with diagnoses of multiple fractures to ribs on left side, a left pinky fracture, and a UTI (urinary tract infection). When Resident #2 discharged from the hospital and returned to the facility, she had an additional diagnosis of a left pneumothorax (deflated or collapsed lung). The continued investigation determined that the facility failed to provide a safe transfer with a mechanical full-body lift for two out of two residents reviewed (Resident #16 and #41). Resident #16 got transferred by a temporary nurse aide (TNA) with a full-body mechanical lift without assistance from additional staff. During the transfer, Resident #16 fell from the full-body mechanical lift and hit her head causing an abrasion. During observations of Resident #41 and #16 determined incorrect usage of the appropriately sized sling (fabric material used to lift people up with the mechanical full-body lift. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 49 residents. Findings included: 1. Resident #103's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident #103's MDS included diagnoses of cancer, high blood pressure, and reduced mobility. In addition, the MDS identified Resident #103 required limited assistance of one person with bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, personal hygiene, and toilet use. Documentation showed Resident #103 frequently incontinent of urine and occasionally incontinent with bowel movements (BM). The Incident Note dated [DATE] at 3:30 AM indicated that a certified nurse aide (C.N.A.) found Resident #103 sitting on his bottom in front of his bed. Resident #103 reported that he took himself to the toilet to have a bowel movement (BM). Resident #103's description said he took himself to the bathroom and fell onto his bottom upon getting back into his bed. No injury or discomfort to the body. Physician notified by fax. The staff's action at the time of the incident included assessment of range and body for injury. Vital signs assessed, interviewed Resident #103, and assisted him back to bed. The door left open as an intervention to visualize the resident. The Interdisciplinary Notes dated [DATE] at 5:59 AM indicated that during the 10:00 PM until 6:00 AM shift, Resident #103 got up to the restroom by himself. The Interdisciplinary Notes dated [DATE] at 11:24 AM documented the staff provided nightly reminders to not get up to the bathroom by himself but he frequently did. Resident #103 noted to have stiff movements and refused suggestions to try Tylenol. The staff noticed an increase in urination for him. The Incident Note dated [DATE] at 12:15 AM indicated that the C.N.A. noted Resident #103's call light on. Once the C.N.A. answered the call light, they observed Resident #103 on the floor leaning against the door. Resident #103 denied knowing how he fell. The nurse noted two abrasions to his left occipital and a skin tear to his right elbow with no edges to approximate. Two staff members assisted Resident #103 into a standing position and walked him with a gait belt to the bathroom. Upon notifying the physician, the nurse received an order to start a neurological assessment (neuro) and the nurse requested a urinalysis (UA). The provider told the nurse to call Resident #103's provider in the morning and schedule and appointment. Resident #103 reported his age and explained he didn't feel the hospital could help him. The nurse notified the provider that he refused to be seen in the ER. Resident #103 received counseling multiple times to not get up alone but he couldn't repeat or voice understanding. Resident #103 did bump his head and had a 2 CM pink abrasion to his left upper occipital area. Resident #103 refused the suggestion to go to the ER replying that nope he didn't need to go there. The Interdisciplinary Notes dated [DATE] at 1:36 AM documented that Resident #103 had a skin tear observed to his right elbow measuring 1.5 centimeters (CM) by (x) 1 CM. Resident #103 did bump his head and had a 2 CM pink abrasion to his left upper occipital area. A mid left occipital abrasion noted measuring 1 CM x 1 CM. Resident #103 denied pain and refused to transfer to the emergency room (ER), replying that he didn't need to go there. The Interdisciplinary Notes dated [DATE] at 1:43 AM recorded that Resident #103's call light alerted the C.N.A. at 12:15 AM. As the C.N.A. entered the room, they noted Resident #103 on the floor leaning against the door. Active range of motion to the upper and lower extremities completed with a neuro sheet started. Resident #103 showed weakness but could walk after he got his bearings. At the time Resident #103 noted to be incontinent with urine. A skin tear observed to his right elbow measuring 1.5 CM x 1 CM. The nurse observed two areas to his left occipital, one 2 CM abrasion and one is a superficial slit to his left occipital. The nurse noted some bruising beginning around the sites. A UA completed due to recent increase in urination and the urgency to get up alone. Resident #103 only complained of pain to his right hand to his finger tip. The nurse attempted to call his Power of Attorney (POA) but got a computer-generated response that the caller wasn't accepting calls at that time. The Interdisciplinary Notes dated [DATE] at 3:16 AM recorded that Resident #103 continued to have increased incontinence and confusion. He needed assistance of one to two to walk into the bathroom. His temperature measured at 99 degrees. The Interdisciplinary Notes dated [DATE] at 7:17 AM documented that Resident #103 continued to have confusion, weakness, and increased incontinence. Breath sounds noted to be increased with increased congestion at the time. Resident #103 noted to not be able to answer questions correctly. After calling the provider, received an order to transfer him to the ER to evaluate and treat. After the nurse attempted to call the POA without a response, they called the brother to give an update. The Emergency Documentation dated [DATE] at 7:58 AM documented that Resident #103's blood pressure increased while in the ER. The ER staff gave 4 of morphine (pain medicine) and 10 of labetalol (blood pressure medicine), which successfully controlled his blood pressure. As a preventive for seizure, Resident #103 received Keppra. Resident #103's POA understood the diagnosis and his terminal status. The POA agreed to the plan for a hospice consult. The Diagnostic Results dated [DATE] at 9:52 AM indicated an impression of an acute subdural hemorrhages left supratentorial compartment. The left lateral subdural hemorrhage was large. There was an associated mass effect and midline shift. The Interdisciplinary Notes dated [DATE] at 2:58 PM indicated that Resident #3's POA notified the facility that he was admitted to the hospital. The History and Physical report dated [DATE] documented that Resident #103 fell on [DATE]. The hospital didn't have a report of the description of that fall. Since that fall, Resident #103 had worsening confusion. His POA explained that he normally could speak and knew his name, location, and year. At the time in the ER, Resident #103 would not answer any questions. The facility nursing staff noted cloudy urine two days ago and contacted his provider but had not heard anything back. At the nursing home, Resident #103's blood Oxygen (O2) saturation (sat) measured at 85 percent (%), but he didn't receive any O2. At the time of the evaluation in the ER, his O2 sat measured 97%. The ER nurses reported that they required the full strength of two staff to get him from the chair to his bed. The nursing home staff reported that he could ambulate with an assist of one person with his walker. Per his medication list, Resident #103 only took a baby Aspirin. Every time the staff attempted to touch, even gently, Resident #103 he moaned very loudly as in pain. The Assessment/Plan section indicated Resident #103 had a subdural hematoma, acute (buildup of blood on the surface of the brain). The Physician discussed the plan with the POA and decided on comfort measures due to Resident #103's terminal prognosis. The Neurosurgeon didn't think Resident #103 was a good candidate for surgical intervention. The Interdisciplinary Notes dated [DATE] at 8:27 AM recorded that Resident #103 passed away at 6:45 AM at the hospital. Resident #103's Care Plan identified an undated problem that he had a potential for injury related to a history of falls prior to admission, impaired mobility, often walked without a walker, even after education to use the walker with staff, use of a front wheeled walker and a history of dementia. The Care Plan lacked direction to the staff to make frequent rounds on Resident #103 or to ensure the door to his room stayed open. The [DATE] MAR (Medication Administration Record) revealed an order to give two tablets of Tylenol 325 MG (milligrams) every 4 hours as needed. The MAR only included one dose administered on [DATE] at 4:30 AM. The MAR contained no additional documentation after [DATE] of Resident #103 receiving Tylenol after his fall on [DATE]. On [DATE] at 8:56 AM, Staff BB, Licensed Practical Nurse (LPN), reported that Resident #103 rarely used his call light and often got up by himself. Resident #103 would say that he would do what he wanted, when he wanted. Staff BB explained that the staff should checked on him at least once every one to two hours. She explained that he transferred with an assist of one staff member and his walker. Staff BB reported that he had a history of falls and received education to keep his door open but often would not. When he fell on [DATE], the aide found him sitting on the floor with his back leaning on the door going into his room, He had some bleeding on the back of his head on the right occipital area. He had an abrasion with a little of bleeding, but he did not have a hematoma. She thought the abrasion was 2 cm x 2.5 cm. She informed the resident that he should go the hospital for x-rays as he had a bump on his head. He refused as he felt he was too old and did not have to go. On [DATE] at 11:28 AM, Staff O, C.N.A., reported that the staff should done rounds on Resident #103 every two hours. Staff O explained that he required assistance of one staff member with a walker and a gait belt. She reported that she thought that was his first fall that night. Staff O added that he did have fall interventions on his care plan that included use of the call light, which the resident never used but threw on the floor, and to keep paths clear for him. Staff O commented that they put gripper socks on him, kept the walker beside him, and kept the door open. The night he fell on [DATE], she heard him screaming. Upon getting to his room, she couldn't open his door as he leaned against it. Staff BB helped her open the door and they found him sitting on the floor. Resident #103 had blood on the door and a little on the floor, as he bled from the back of his head. Staff O thought he was trying to close the door and lost his balance. Staff BB and Staff O helped him back to bed with a gait belt. Staff BB checked his vital signs, checked his legs, and arms to make sure they could bend. He appeared to be in a lot of pain. After that he kept complaining about a headache. Staff O remembered that he kept refusing to go to the hospital. He kept saying he was [AGE] years old and didn't feel like he needed to go. Staff O recalled remembering him yelling and screaming that he was in a lot of pain afterward. Staff BB did not work the day he went to the hospital. On [DATE] at 1:24 PM Staff N, C.N.A, Certified Medication Aide (CMA), and restorative aide (RA), reported that the staff were to check on residents every two hours, and more frequently if the resident had a history of falls. She could not recall if the resident had a history of falls or what the Care Plan said regarding how he transferred. On [DATE] at 3:25 PM, the DON (Director of Nursing) reported the she didn't work when Resident #103 fell and she did not know what type of interventions he had on his care plan before the fall. On [DATE] at 3:57 PM, the Administrator reported Resident #103 had constantly tried to get up to go to the bathroom in the middle of the night. The Administrator explained that they had the physician check him for a UTI (urinary tract infection). They tried to keep his door open, but he did not always like that, so he would get up and shut it. The undated facility policy titled: Fall Reduction Protocol documented the following: a. All falls will be discussed weekly during the Rehab Team meeting on Thursdays. b. The Care Plan Coordinator/Quality Assurance representative will summarize the falls that occurred the previous week. c. Current interventions will be initiated as deemed necessary by the Rehab Team. d. If a restraint is needed, least restrictive devices are considered first. e. Fall education is also provided at the mandatory CNA and nurse's meetings along with being addressed in the daily huddle meetings as needed. 2. Resident #25's MDS dated [DATE] identified a BIMS score of 00, indicating severe cognitive impairment. The MDS included diagnoses of anxiety disorder, atrial fibrillation (A-Fib, an abnormal heart rhythm), and high blood pressure. The MDS indicated that Resident #25 required total dependence of one person with locomotion on and off the unit. Resident #25 used a walker and a wheelchair for mobility devices. The Care Plan problem dated [DATE] indicated that Resident #25 had a self-care deficit related to an incontinence, vertigo, and she required staff assistance with all activities of daily living (ADLs). The Care Plan lacked documentation regarding safety outside of the facility while in a vehicle. The Interdisciplinary Note dated [DATE] at 4:59 PM documented that at 11:00 AM, Staff A, Nurse Manager, received a call regarding an incident with Resident #25 in the wheelchair van going to her dentist appointment. The van hit a curb causing Resident #25's wheelchair became loose in the straps and she tipped over. The driver call an ambulance and Staff A went to Resident #25 to assess her. Resident #25 went to the hospital following the incident. At 4:30 PM the hospital called to report that the x-rays showed a small brain bleed. Resident #25 admitted to the hospital for observation and a neurological follow-up. The Interdisciplinary Notes dated [DATE] at 8:39 AM labeled as a late entry for [DATE] documented by Staff A, Nurse Manager, received a phone call regarding an incident with Resident #25. Staff A went to Resident #25 at the dentist's office in the wheelchair van. Upon arriving to the wheelchair van, Staff A observed Resident #25 sitting in the wheelchair. Staff H, Wheelchair Van Driver, stood at the front of the bus. The van contained pieces of the wheelchair broken on the floor. Staff A observed Resident #25's wheelchair not buckled with the safety straps. Staff H reported that he secured all the straps before leaving the facility. The ambulance crew reported that the wheelchair tipped to its side with Resident #25 laying on her right side. Assessment of Resident #25 determined impaired range of motion (ROM) to her right side and that she wouldn't lift her arm. Staff A explained that Resident #25's baseline ROM to her arms due to a history of arthritis to both shoulders. Staff A checked Resident #25's ROM. Reside[TRUNCATED]