**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents' environment were as free of accident hazards by failing to: 1. properly secure wheelchairs in the facility's van for 1 (#3) of 8 (#1-#5, #R1-#R3) sampled residents who utilized wheelchairs during facility transport; and 2. train transportation staff on the correct procedure for utilizing the van's restraint system. This failed practice resulted in an Immediate Jeopardy (IJ) on 08/24/22 at 4:45 p.m. when S4CNADriver placed Resident #3, who utilized a wheelchair, in the facility's transport van with the j-hook of the van strap applied to the wheel instead of the frame of Resident #3's wheelchair. The driver made a turn and the resident flipped backward and hit her head which resulted in 3 lacerations to the back of her head. The resident was sent to the ER (emergency room) for scalp laceration repair that required 7 skin staples. S1ADM was notified of the Immediate Jeopardy on 11/30/2022 at 2:50 p.m. The IJ was removed on 12/01/22 at 3:15 p.m., when the facility presented an acceptable POR (plan of removal) prior to the survey exit, which by observation, record review, and interview, the survey team verified was in progress. The POR read: Immediate Action To assure resident #3 and all wheelchair bound residents identified (13) with potential to be affected by improperly securing of safety straps; facility has implemented the following to assure residents are as free from accident hazards. As of 12/01/22, S1ADM will update Company Vehicle Policy to include Safe Vehicle, Safe Wheelchairs, Safe Procedures (unloading and loading wheelchairs), Safe Planning(wheelchair placement), and Emergency Safety Procedures to ensure proper application of safety straps are being used in accordance with policy. On 11/30/22, S10Maintenance inspected all safety straps on Eco line Van and Sprint Van for proper functions- Ford Sprint Van is not equipped with shoulder strap and as of this date (11/30/22) will only be utilized for non-wheelchair bound residents. Ford Eco-line Van is fully equipped with functioning safety straps, including shoulder strap. Supervision To ensure resident (#3) and all wheelchair bound residents are secured properly with all straps per manufactures instructions. Training Residents who are wheelchair bound will use the Ford Hi Top van with pelvic and shoulder attachment on transports. On 11/30/22 an immediate in service was held with facility van drivers. The instructor was S3Owner and participants were S6CNADriver, S7MaintDriver, and S5CNATransport. These three employees listed will be the only staff allowed to transport residents; unless a new employee is trained on driving, loading, and securing residents. In service on the Ford Eco Line will include Step 1: Position the wheelchair, Step 2: Attach the front tie downs, Step 3: Attach rear tie downs, Step 4: S-Hook placement on solid part of wheelchair frame, Step 5: Attach the lap belt, Step 6 Attach shoulder belt per manufacture instructions for securing wheelchair bound residents. In service will also include once resident is placed on lift when to lock and unlock wheelchair brakes. Staff will be educated on how to keep one hand on the resident's wheelchair during operation of the lift for Ford Eco-Line. Repeat demonstration was performed immediately by drivers S6CNADriver, S7MaintDriver, and S5CNATransport on 11/30/22. As of today, 12/01/22 the following employees performed repeat demonstration: S12CNA, S13CNA, S14CNA, S11ADON, S15CNA), S16Clerk, S10Maintenance, S2DON, and S1ADM. New hires with potential to drive or assist with loading the van will be trained on proper placement of straps and wheelchair brakes ensuring that the chair is placed correctly and secure per manufactures instructions. Evaluation All day shift CNA's (Certified Nursing Assistants) will start in servicing on 12/01/22 for the Ford Eco Line Van with proper lift and strap use by S3Owner with return demonstration by all dayshift CNA's. For Quality Assurance purposes to ensure staff members are in compliance with application of safety straps (J-Hook), S1ADM will meet with transportation drivers on a weekly basis, review and discuss monitoring/findings, and provide direction, guidance, and recommendation in area of concern three times a week. This will last up to 4 weeks January 4, 2023 or until compliance is met. Quality Assurance S2DON and S11ADON team will monitor drivers and S1ADM weekly of proper operation of safety straps and brake usage of wheelchair residents. Quality Assurance will last up until 4 weeks or until compliance is met. Compliance will be met on January 4, 2023. Findings: Review of the facility's policy, Company Vehicles failed to include procedures for safe transportation of residents and proper use of the van straps and lift. Review of manufacturer's instructions for van straps, Q'Straint Use and Care Manual QRT-360 4-point wheelchair securement system, read in part: J-Hooks must be attached to the WC19 compliant chair securement points or a solid wheelchair frame for all other wheelchairs (no spokes or movable components) at an approximate 45 degree angle with floor .Compliant Shoulder and Pelvic Belt Restraint must go across occupant's shoulder and pelvis (lap), and not be worn twisted or held away from occupant's body by wheelchair components. We recommend using both a pelvic and shoulder belt together and not individually since it will compromise the performance of the system. The QRT-360 4-Point wheelchair securement system should not be operated by anyone who does not have fully comprehension of how the system works or if the system is not working properly. Further review revealed illustrations of the equipment with labeled parts. Review of the entire system with depictions with wheelchair placement revealed straps/J-hooks secured to wheelchair frame (not wheel spokes) with two in front and two in back. A lap and shoulder belt was also illustrated in the completed setup. Resident #3: Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE] with diagnoses including Complete Traumatic Amputation at level between left hip and knee, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Generalized Muscle Weakness, and Muscle Spasm. Review of Resident #3's quarterly MDS (Minimum Data Set) dated 10/04/22 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact. Further review revealed the resident used a wheelchair. Review of Resident #3's nursing notes revealed in part: 08/24/22 4:45 p.m., S4CNADriver FaceTime called and advised that while transporting resident, wheelchair overturned with resident in it .[Local ambulance service] called and advised location to transport resident to hospital for assessment .ER doctor via FaceTime informed nurse that resident had a small cut on the back of head. 08/24/22 7:45 p.m., ER nurse reports resident will be returning to facility, laceration to back of head with staples, .9:15 p.m., RFH (returned from hospital) .staples to back of head noted and intact . Review of S4CNADriver's handwritten statement dated 08/25/22 revealed in part: took Resident #3 to the __ in (city name) .After her appointment we loaded up, traveled to (city name). Stopped at the store __ to pick up items for the nursing home. I loaded Resident #3 up in the van, hooked all 4 straps, seat belted her down, shook the chair (as I did each time I loaded her) for securing her. All was well, closed the doors, got in the van and pulled off. I exited the parking lot, took off down the street __ leading to the interstate. I looked in my rear view mirror and shouted (Resident #3's name). She hollered and I said, what happened? How did you do that? I was in my turning lane. I had to get all the way over in order to assist her. Once I was in a safe place I got out the van, got to the back of the van and phoned 911 at 4:39 p.m. I recognized my mistake #1 exiting the parking lot on a slant. #2 hooking the hooks to the wheels instead of the bars under the chair. Review of an attached page read in part: when I opened the back doors to the van, Resident #3 was lying flat on her back at an angle .She had bleeding from the back of her head. Review of Resident #3's hospital records revealed in part: 08/24/22 17:21 (5:21 p.m.) resident presented to the emergency department for evaluation due to fall from her wheelchair. The patient was in an agency van just prior to ED (emergency department) evaluation when the wheelchair fell backward and the patient hit her head on the floor of the van. The patient has a scalp laceration. Laceration repair: occipital linear superficial wounds. Laceration #1- length 3 cm (centimeters), closed with 3 staples. Laceration #2- length 2 cm, closed with 2 staples. Laceration #3- length 2 cm, closed with 2 staples. A total of 7 staples. On 11/29/22 at 10:07 a.m., an interview was conducted with Resident #3 who was asked to recall the incident. She stated that S4CNADriver took her to her appointment. After the appointment, they stopped to a store. After shopping, S4CNADriver loaded her into the van in her wheelchair and strapped her down. Everything seemed fine so S4CNADriver got into the driver's seat and began driving out the parking lot. When S4CNADriver made a left turn, the back wheels on the left side of the van hit a curb causing the van to jump up. When this happened, she fell backward in her wheelchair hitting her head on the van's floor. She stated that there was a lot of blood from her head. The ambulance transported to the hospital where it took 7 skin staples to repair the laceration to her head. She then parted the hair behind her head and stated she had scars behind her head. Three scars observed in a disrupted pattern to left posterior skull. At this time resident began to cry and stated that since the fall it seemed like everything hurts and she has occasional headaches that she did not experience prior to the fall. On 11/29/22 at 10:32 a.m., a phone interview was conducted with S4CNADriver who stated she was no longer employed at the facility. She was asked to recall the incident involving Resident #3 and explained it in detail as was documented in her witness statement. She stated that she hooked the straps to the residents chair and shook the chair to make sure it was sturdy. She was driving down the road after pulling out the store driveway when she looked in her rear view mirror and saw that the resident was not visible. She yelled out to the resident and the resident began yelling so she pulled over to a safe area on the side of the road, called 911, and video called the nurse at the nursing home. She stated the resident fell backward in her wheelchair and was bleeding from the back of her head. The ambulance took Resident #3 to the hospital. S4CNADriver stated, I made a mistake .I hooked the straps to the wheels, not the cross bar. She stated that the straps of the j hooks should have been placed on the frame of the wheelchair not the wheels. She further stated she had been transporting residents for many years and knew better. On 11/29/22 at 11:59 a.m., an observation was conducted of S5CNATransport and S6CNADriver loading Resident #3 into the facility's gray Ford Sprinter van. S3Owner was present during the observation. Once the resident was lifted into the van, S6CNADriver began securing the J hook straps to Resident #3's wheelchair. S6CNADriver hooked two front straps and two rear straps onto the wheels of the resident's wheel chair. The hooks were observed as the same hooks illustrated in the operator's manual as the J hook. The hooks did not have a secure closing on the ends. S6CNADriver then stepped out to allow closer observations. At this time, S3Owner was standing next to S6CNADriver at the side doors in view of the resident. All 4 straps were observed on the wheelchair wheel. There were no straps observed on the frame of the wheelchair. When asked if these were all the straps required for transport, S6CNADriver stated yes. S6CNADriver then secured the resident's lap belt, a shoulder strap was not applied. S6CNADriver was asked if this was how staff secured the straps, to the wheels of the wheelchair, and she replied yes. She was again asked if any other straps needed to be applied to the frame of the wheelchair, and if these were the only straps required to secure the resident, and she said yes. At this time S3Owner confirmed this was the proper placement of the straps, 4 J hooks applied to the wheel with a strap across the resident's lap. S6CNADriver confirmed she was done securing the resident's wheelchair and that the resident was ready for transport. S6CNADriver and S5CNATransport entered the driver and passenger seats respectively and drove off with the resident. On 11/29/22 at 3:20 p.m., Resident #3 had returned to the facility. An observation was conducted of Resident #3 was still loaded inside the van with straps in place. S1ADM, S5CNADriver, and S6CNADriver were present. The straps of the J hooks were now observed to the frame of the resident's wheelchair. There was no shoulder belt in place, only a lap belt. No shoulder strap attachments were observed in the back of the van where Resident #3 was located. S5CNATransport and S6CNADriver were asked why the straps were placed differently. Resident #3 then replied, to satisfy the state. Both CNAs confirmed straps were placed on wheels this morning as previously observed. They were asked which way was the correct placement, on the wheels or frame? S5CNATransport stated that both methods were correct. S6CNADriver stated she was not sure why, but that staff placed them on the wheels. S6CNADriver confirmed the straps of the J hooks should have been secured to the frame of the resident's wheelchair. Resident #3 stated that staff normally hooked the straps to her wheels and that today on her return trip hooked it to the frame. S5CNATransport and S6CNADriver then stated that Resident #3 preferred that staff strap the hooks on the wheels, so that's what they did, and it was the resident's preference. S1ADM confirmed Resident #3 fell on 8/24/22 because S4CNADriver hooked the straps to the wheel. She confirmed staff did not follow the manufacturer's instructions and that resident was not properly secured during transport. On 11/30/22 8:09 a.m., an interview was conducted with S7MaintDriver who stated that he normally drives the white high top van and does not drive the gray Ford Sprinter van (the one observed on 11/29/22.) He stated he straps the resident across the lap and hooks the straps to the frame of the chair. When asked about a shoulder strap he stated, I think that maybe there is one that goes across the shoulder but he wasn't sure. Interviews conducted with residents who had been transported in the facility's van from August 2022-November 2022 revealed the following: Resident #1 Review of the resident's admission MDS dated [DATE] revealed she had a BIMS score of 15, indicating she was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 11/02/22 and 11/10/22. During an interview on 11/29/22 at 2:30 p.m., Resident #1 confirmed she had been transported to medical appointments via the facility van in her wheelchair. She stated that whenever they transport her the staff strap the safety belts to the wheels of her wheelchair and then one strap goes across her waist. Resident #2 Review of the resident's quarterly MDS dated [DATE] revealed she had a BIMS score of 12, indicating she was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 09/22/22 and 11/21/22. During an interview on 11/29/22 at 3:20 p.m., Resident #2 confirmed she had been transported to medical appointments via the facility van in a wheelchair. She stated that staff hooked straps onto to the wheels of her wheelchair for transport. Resident #5 Review of the resident's admission MDS dated [DATE] revealed she had a BIMS score of 14, indicating she was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 09/19/22, 10/06/22, and 11/02/22. During an interview on 11/29/22 at 2:30 p.m., Resident #2 confirmed she had been transported to appointments via the facility van in a wheelchair. He stated that whenever they transport him, the staff secure the safety belts to the wheels of his wheelchair with one strap across his waist. Resident #R1 Review of the resident's admission MDS dated [DATE] revealed she had a BIMS score of 14, indicating he was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 09/27/22. During an interview on 11/30/22 at 11:00 a.m., Resident #R1 confirmed he had been transported in a wheelchair in the facility van. He stated that whenever he is transported, the staff hook the safety belts to the wheels of his wheelchair using 4 straps to the wheels plus a lap belt. Resident #R2 Review of the resident's annual MDS dated [DATE] revealed she had a BIMS score of 14, indicating he was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 09/13/22, 09/27/22, and 10/20/22. During an interview on 11/29/22 at 2:30 p.m., Resident #R2 stated he was transported regularly in the facility van in his wheelchair. He stated that whenever staff transport him, the staff strap 4 safety belts to the wheels of his wheelchair and apply a lap belt; no mention of a shoulder strap. Resident #R3 Review of the resident's quarterly MDS dated [DATE] revealed she had a BIMS score of 15, indicating he was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 10/08/22. During an interview on 11/30/22 at 10:30 a.m., Resident #R3 confirmed she had been transported to via the facility van in a wheelchair. She stated that staff hooked straps onto to the wheels of her wheelchair for transport. He stated staff hook the straps to the wheels of his wheelchair and apply a lap belt. On 11/29/22 at 2:07 p.m., in an interview with S8CNA, she stated she was trained on the van about 3 weeks ago after Resident #4's fall. S1ADM conducted the training and demonstrated to staff to strap the wheelchair down by attaching each strap to each wheel. She further stated that each CNA (Certified Nursing Assistant) at the training had to perform a return demonstration. On 11/30/22 at 9:40 a.m., in an interview with S9CNA, she stated S1ADM trained her 3 weeks ago on van transportation. She stated she was taught to hook the straps front straps on the front of each wheel and the back straps on the back wheels. On 11/30/22 at 10:55 a.m., an interview and record review was conducted with S1ADM. She stated that the facility owned a white high top Ford van and a gray Ford Sprinter van. She stated that shoulder straps were used as needed and if the resident can wear it. She was asked to explain what can meant and under what circumstance a shoulder strap would be used. She stated that it depended on which van the resident rode and was also based on resident's needs/condition. She was informed a shoulder strap was not observed in the gray van used to transport Resident #3, nor was there any shoulder strap attached to the van frame. She stated that a shoulder strap was not required in the gray van, but it was required in the white van. She stated that both vans were equipped with the same QRT-360 strapping system. The QRT-360's manufacturer's instructions were reviewed with S1ADM at this time. She then confirmed that a shoulder strap was required to ensure integrity of the strapping system. She then stated that the gray Sprinter van used to transport Resident #3 on 11/29/22 was borrowed from a sister facility after it was wrecked sometime after Resident #3's incident. She stated that the facility had not inspected the van or the van's strapping system to ensure the van was in proper working order before transporting residents. She further stated that it was her error that she failed to do this. On 11/30/22 at 4:35 p.m., S1ADM observed the gray Ford sprinter van and confirmed the van was not equipped with shoulder straps for wheelchair residents. On 11/30/22 at 5:27 p.m., S3Owner stated that when he purchased the gray Ford Sprinter van it did not come with lift and straps. Another company installed the lift and straps and a shoulder strap was not installed. He further stated that the van never had a shoulder strap. He confirmed that the QRT-360 belt system was installed in the gray van. He reviewed manufacturer's instructions which noted that strap system should have included a shoulder strap. There were no instructions to use the system as a lap strap only although he continued to insist that it could be used without a shoulder belt. He further stated that the manufacturer's instructions provided to surveyors on yesterday were printed off of the internet to provide us with what we requested, and that the facility did not have any manufacturer's instructions onsite. He confirmed he was not aware of the information stated in the instructions because the van did not come with manufacturer's instructions for the straps after install. He confirmed S5CNATransport did not strap the resident according to manufacturer's instructions as observed on 11/29/22.

Based on record review, and interview; the facility failed to administer its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to: 1. ensure the safety of Resident #3 during van transport, 2. ensure staff were properly trained and competent to secure wheelchair residents in the van according to manufacturer's instructions for use, and; 3. ensure all transportation staff were retrained on proper wheelchair restraint after Resident #3's incident and develop policies and procedures for safe tranportation to prevent future incidents. This failed practice resulted in an Immediate Jeopardy (IJ) on 08/24/22 at 4:45 p.m. when the facility failed to develop policies and procedures after staff placed Resident #3, who utilized a wheelchair, in the facility's transport van with the j-hook of the van strap applied to the wheel instead of the frame of Resident #3's wheelchair. The driver made a turn and the resident flipped backward and hit her head which resulted in 3 lacerations to the back of her head. The resident was sent to the ER (emergency room) for scalp laceration repair that required 7 skin staples. The facility also failed to retrain all transportation staff on the correct procedure for utilizing the van's restraint system to prevent future incidents. S1ADM was notified of the Immediate Jeopardy on 11/30/2022 at 2:50 p.m. The IJ was removed on 12/1/2022 at 3:15 p.m., when the facility presented an acceptable POR (plan of removal) prior to the survey exit, which by observation, record review, and interview, the survey team verified was in progress. The POR read: To assure all staff members have an understanding on the vehicle policies and procedures of van operation. As of 12/01/22, S1ADM will update policy to include training of the proper application of safety straps to secure wheelchairs. On 11/30/22 13 residents who are in wheelchairs were identified for potential risk of improper use of brake and safety strap usage on transportation van. On 11/30/22 S10Maintenance checked all straps on the van to ensure they were properly working. Ford Sprinter van will be used for residents that do not require to be transported by wheelchair/lift. Supervision Facility will develop and implement a policy on safe transporting of residents in wheelchairs. Policy will be completed on 12/01/22. S1ADM will randomly monitor transportation drivers S6CNADriver, S7MaintDriver, and S5CNATransport. Day shift CNA's (Certified Nursing Assistants) will also be in serviced on proper application of safety straps to assure residents are free of accident hazards, three times a week for four weeks (January 4, 2023). Administrator will instruct if any deficient practice noted. Training On 12/01/2022 S1ADM will review policies on Safe Transport of Wheelchair Residents with drivers and ensure a copy of the policy will be placed in the van. New hires with potential to drive the van or potential to assist in loading a wheelchair bound resident will be trained on proper placement of straps and wheelchair brakes ensuring that the chair is placed correctly and secured per manufacture instruction. Evaluation On 12/01/2022 for Quality Assurance purposes and to ensure staff members are in compliance with application of safety straps (J-Hook), Administrator will meet with transportation drivers on a weekly basis, review and discuss monitoring/findings, and provide direction, guidance, and recommendation in area of concern. Quality Assurance Coordinator S11ADON and or S2DON will monitor drivers and S1ADM randomly three times a week for four weeks (January 4, 2023). Quality Assurance will instruct if any deficient practice noted. Compliance will be met on January 4, 2023. This deficient practice continued at a potential for more than minimal harm for the 13 wheel-chaired residents who had the potential to be transported in the facility's van. Findings: Cross reference findings at F689 Review of the facility's policy, Company Vehicles failed to include procedures for safe transportation of residents and proper use of the van straps and lift. On 11/30/22 at 9:36 a.m., S1ADM stated that the only policy she had on transportation was the one given on yesterday Company Vehicles. She further stated that the facility did not have any other policies regarding resident transportation or safe resident transport. She stated that staff should transport residents according to their training. On 11/30/22 at 10:41 a.m., an interview and review of in-service records dated 8/25/22 and 11/2/22 was conducted with S1ADM. S1ADM stated that she conducted the in-services where she demonstrated the proper placement of straps to staff. She stated that S5CNATransport, S6CNADriver, and S7MaintDriver were the facility's designated transportation staff, but that any CNA could transport residents. She confirmed that S5CNATransport, S6CNADriver, and S7MaintDriver were not retrained on 8/25/22 after Resident #3's incident. On 11/30/22 at 10:55 a.m., another interview and record review was conducted with S1ADM. She confirmed that Resident #3 fell in the van because S4CNADriver hooked the straps to the wheel not to the frame of the resident's wheelchair as stated in the manufacturer's instructions. S1ADM stated she conducted the QA after Resident #3's fall in which she directly observed staff for proper placement of the straps on the wheelchair for 4 weeks. She reviewed the QA forms and confirmed it stated proper placement of straps on wheel. She stated that it was an error. On 11/30/22 at 5:27 p.m., S3Owner stated that he was responsible for training staff on the proper way to strap residents' wheelchairs in the van. He had the van lift and straps installed after purchasing the gray Ford Sprinter van which did not come with manufacturer's instructions for the straps and lift. He stated that a shoulder strap was not installed and that the van never had a shoulder strap. He confirmed that the QRT-360 belt system was installed in the gray van. He reviewed manufacturer's instructions which noted that strap system should have included a shoulder strap and J hooks should be attached to the frame of the wheelchair. He confirmed he was not aware of the information stated in the instructions regarding the shoulder strap. He further stated that the manufacturer's instructions provided to surveyors on yesterday were printed off of the internet to provide us with what we requested because the facility did not have the manufacturer's instructions onsite. He confirmed S5CNATransport did not strap the resident according to manufacturer's instructions as observed on 11/29/22.