**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations the facility failed to properly secure resident #5's wheelchair in the facility's transport van for 1(#5) of 3 (#1, #2, and #5) residents reviewed for accidents. The deficient practice resulted in actual harm of Resident #5 on 09/12/2022 when the resident was being transported from an appointment back to the facility via wheelchair on a facility van. Resident #5's wheelchair was not properly secured to the van with four point strap restraints resulting in the wheelchair flipping backwards on to the floor. A local ambulance service was on sight and transported Resident #5 to a local hospital emergency room (ER), where she was diagnosed with one broken rib and contusions to her left shoulder, arm and scalp. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facilities Sec 5.4 Driver and Vehicle Safety Policy dated November 2013 revealed in part: Driver Training 5.4.11: All drivers, whether driving company vehicle, personal vehicle or rental vehicle will be in-service in the Driver and Vehicle Safety Policy before any employee is permitted to drive for the company. In addition, the following training modules are used: Driver safety videos On line driver safety training Employees who drive company vehicle receive additional in-servicing in the following: Loading and unloading of residents, including viewing in [NAME] and Ricon Series Lift and Sure lock Tiedowns video and hands on practice. Securing wheelchairs and other equipment Before transporting residents in the facility van, facility van drivers must (1) successfully complete all parts of the training; and (2) demonstrate to an authorized trainer that the van driver can properly load, unload and secure residents in the van. The Checklist for Authorizing New Drivers and the Competency Demonstration for Securing Residents in the Van should both be completed before the facility van driver transports residents. Review of Securing Residents in Van - Competency Demonstration dated November 2013 revealed in part: Strap passenger's wheelchair front first from lower bottom bar on top of wheel. Straps should attach to a solid, structural frame member of wheelchair. Apply brake on the wheelchair. Strap rear of the wheelchair to the floor of the vehicle. Any fittings should be firmly engaged and locked into the appropriate slot of the track. Secure the passenger with a seat or lap belt. Prior to transport, make a final check of all secured passengers to ensure that all straps are properly attached. If there are any wheelchairs, be sure that they are secured and there is no possible movement from the front to rear or side to side. Review of Resident #5 clinical records revealed an admit date of 05/20/2021 with diagnosis not limited to Polyneuropathy, Rheumatoid Arthritis, Heart Failure and Dementia. Review of Resident #5 MDS (Minimum Data Set) dated 10/11/2022 revealed a BIMS (Brief Interview of Mental Status) score of 15 indicating Resident #5 was cognitively intact. Resident #5 required total dependence for transfers and locomotion on and off the unit. Review of Resident #5 care plan revealed she needed extensive assistance with personal hygiene, toilet use, dressing and bed mobility. Interview 12/05/2022 at 9:00 a.m. Resident #5 reported that her wheelchair had turned over in the van and she had broken a rib as a result. She further revealed that her wheelchair was not tied down the right way and her chair fell over. She said S1 Transport Driver just didn't do it right. She was shook up, her left side hurt and her elbow was bleeding. Interview 12/05/2022 at 2:30 p.m. S4 Transport CNA (Certified Nursing Assistant), reports that on the day of the accident I was with the resident, and the Driver (S1 Transport Driver) coming back from a doctor appointment. The resident was lifted into the van by the lift and secured by the driver as she got onto the van. When they made the last turn to the nursing home, they began to climb a grade and the wheelchair flipped backwards. They pulled up to the facility, the driver went and got help, she went to the resident and stayed with her on the floor of the van until help arrived. The resident was transported to the ER by a local ambulance service. After the investigation the driver was let go and we all had to in-service and get on the van and lock down a wheelchair to get experience on how to do it. Review of the facility's Employees Report of Accident revealed statement by S1 Transport Driver stating As we left the medical facility on the way to the facility, Resident #5's wheelchair flipped backwards. The wheelchair front wheels lifted and fell backward. She landed on the floor of the bus. Review of Nurses notes from 09/12/2022 revealed the following: 09/12/2022 13:40 S2 DON (Director of Nursing), reported to nurse that resident is being sent to a local hospital ER for evaluation because of fall. It was reported that resident w/c (wheelchair) flipped backward on the van. I was also reported to nurse that resident had a raised area to the back of her head and a skin tear to the left elbow. Grandchild and Responsible Party notified and S9 MD. Signed S3 LPN (Licensed Practical Nurse) 09/12/2022 17:00 resident returned these hours by stretcher via a local ambulance service. DX (diagnosis): contusion of left shoulder, contusion of scalp, fracture of one rib left side. NNO (No New Orders), Follow up contact physician as needed, recheck todays' complaints, continue of care. Review of local hospital ER notes dated 09/12/2022 14:33 revealed Resident #5 had fracture on one rib, left side, contusion to left shoulder and scalp. No prescriptions written. Review of Resident #5 Pain Evaluation completed on return from ER. -Pain in last 5 days resident #5 answered yes- occasionally, does it limit your activities- no, pain rate 6 on scale 00-10, pain management as needed. Review of Physicians orders revealed Resident #5 had the following medications already scheduled: Tramadol 100 mg (milligram) every 8 hours as needed, Neurontin 600 mg every night, Tylenol 1000 mg three times a day for breakthrough pain, if needed. Review of Medication Administration Record from September 2022 revealed from 09/12/2022 through 09/23/2022 required Tramadol at least once a day. Observation 12/06/2022 at 11:45 a.m. S5 Transport Driver and S6 Transport Driver both completed a demonstration of how to lift and secure a resident in a wheelchair on to the transportation van. Interview 12/06/2022 at 11:45 a.m. S5 Transport Driver and S6 Transport Driver, both reported that they had been through all the training and understood how to secure a wheelchair in the van. Interview 12/07/2022 at 10:30 a.m. S7 Administrator reported that the day of the accident the driver came through the front door and told her there was an accident and he needed help. S8 RN (Registered Nurse) was there with her, they both rushed out of the door to the van. Upon arrival they found S4 Transport CNA holding Resident #5's head off the floor, wheelchair was rolled backwards and resident was still strapped in the wheelchair. A local ambulance service happened to be in the drive way too. They assisted in transporting the resident straight to the local hospital ER. Resident was complaining of her left side and arm hurting. Further reported that S1 Transport Driver had been suspended then terminated. Telephone interview 12/07/2022 at 10:46 a.m. S8 RN reported that when they got on the van the wheelchair was on its back with only the back wheels strapped in place. A local ambulance service was on scene and they released the rear wheel restraints to allow the wheelchair to be righted. S8 RN concurred that Resident #5 complained of left side and arm pain and that a local ambulance service took resident immediately to the ER. Telephone interview 12/07/2022 at 10:55 a.m. S1 Transport Driver refused to talk about the incident. Review of the facility's corrective Action Plan dated 10/14/2022 revealed: Problem identified: Van driver failed to secure resident in wheelchair correctly while transporting in a facility van. Plan of Action: randomly monitor that residents in wheelchairs are correctly secured in facility transport vans. Educate van drivers and transport CNAs on securing residents correctly in facility transport vans. Monitoring: Random monitoring of transportation securing 4 point strap restraint system is used correctly. Follow-up for effectiveness: current plan of action effective: yes, date 10/21/2022. The facility has implemented the following actions to correct the deficient practice from 09/12/2022: Staff in-service training after incident - 9/15/2022 - Securing resident in van before transporting- completed by All Van Drivers and Transport CNA (Certified Nurses Aids). Review of QA (Quality Assurance) dated 09/15/2022 revealed Problem: resident flipped over backwards in van due to 4 point strap not engaged with 5 points of action plan: 1. All residents transported in van will be secured in the van by engaging the 4 point strap system. 2. All van drivers will be in-serviced and checked off on the 4 point strap system. 3. Transportation Aids will validate that the 4 point strap system is in place prior to van placed in drive, if not then the Transportation Aid will report to Administrator/Maintenance Director. 4. Transportation Aids will be in-serviced on the 4 point strap system. 5. Maintenance Director/designee will do random off site/on site transportation to ensure that the 4 point system is in place x4 weeks. Random monitoring of transportation 4 point strap restraint system in place: monitored for 4 weeks. Started 09/19/2022, completed 10/21/2022. 48 events monitored and done correctly.