Intake: MI00144784 Based on observation, interview and record review, the facility failed to implement appropriate interventions to prevent a fall for one Resident (R601) of three residents reviewed for falls. This deficient practice resulted in actual harm with R601 sustaining a fall with a right hip fracture requiring surgical interventions. Findings include: A review of R601's electronic medical record (EMR) revealed admission to the facility on 2/1/16 with diagnoses including symptoms and signs involving cognitive functions and awareness, unsteadiness on feet, and pain. R601 scored a 10/15 on the 2/27/24 Brief Interview for Mental Status (BIMS) score indicative of moderate cognitive impairment. R601 was noted to have one fall with no injury and one fall with major injury in section J of the 2/27/24 Minimum Data Set (MDS) assessment. R601's Fall Risk Assessment Tool dated 9/1/23 revealed a fall risk score of 22 points, indicative of a high fall risk. Review of the Facility Reported Incident submitted to the State Agency on 5/23/24 read, in part, .Resident (R601) had a fall on 5/20/24 at approximately 2:30 p.m. Resident initially thought to be without injury .Xray was ordered at 3:30 a.m. the morning of 5/22/24. Pain and BP (blood pressure) increased, so resident was sent to ER (Emergency Room) for x-ray and treatment at approximately 1 p.m. Resident was found positive for fracture that afternoon. Resident had hip displacement corrected by surgery that same afternoon . Review of the History and Physical from [Hospital Name] emergency room revealed R601 sustained an acute angulated intertrochanteric right hip fracture. Review of R601's Progress Notes read, in part, 5/20/24 4:47 p.m. Resident was in her room sitting in her recliner with feet on the floor with grippy socks on her feet. Resident has been yelling wanting to drive a car. CNA (Certified Nurse Aide) and nurse in resident's room several times but resident didn't need anything. CNA called writer to residents' room, found resident lying on her left side of the floor. Resident denies hitting her head, states, she just fell. Resident is complaining of right hip pain, Medical Director (MD) D notified, hip Xray ordered. Resident was assisted to her bed with mechanical full lift and 2 CNA's. Full skin assessment resulted in no injuries or bruising noted at this present time but will continue to monitor as needed. Resident is currently lying in her bed, supine position, napping on and off, resident denies having any pain or discomfort at this time .Licensed Practical Nurse (LPN) A. Review of R601's Physician Note, dated 5/20/24 read, in part, .I was then urgently requested to see her later in the day after she attempted to self-ambulate from her reclining chair to her bed and fell on her left side .As I was leaning over her to examine her left side, she told me that it was the right side that hurts .Assessment .Cognitive impairment .Post fall I have ordered x-ray of the right hip/pelvis/knee and ankle to be done as soon as possible. I have instructed both resident and staff that she is to stay in bed until x-ray results are known . An interview was conducted with CNA B on 6/20/24 at 3:00 p.m. CNA B stated she heard an alarm going off and entered R601's room and found her on the floor. She then radioed for LPN A to come in and look at R601. CNA B stated LPN A never completed a full head to toe assessment on R601 and requested that two CNA's put her back into bed, which CNA B did and confirmed they did not use a mechanical lift but rather a gait belt and slid R601 onto the bed. CNA B confirmed MD D did exam R601 and ordered an x-ray be done as soon as possible, and R601 was to stay in bed until completed. When CNA B returned to work on 6/21/24, she was instructed to keep R601 in bed as the x-ray had not been completed. CNA B stated R601's blood pressure continued to increase but was instructed to let LPN A complete all vitals. An interview was conducted with LPN A on 6/20/24 at 3:08 p.m. LPN A stated R601 was restless all day long on 5/20/24 and wanted to spend as much time with the staff as possible. LPN A stated it was a CNA who placed R601 in her recliner chair and placed the recliner chair in an upright position, not allowing her feet to touch the floor and closed the door. LPN A stated she instructed the CNA to lay R601 in her bed as this was a restraint to have R601 in her chair unable to get out. LPN ' A stated she received a page over the radio to R601's room as she had fallen and upon entering the room did complete a full assessment. LPN A instructed two CNAs to lay R601 back in her bed and notified MD D. LPN A stated MD D took R601's chart after the assessment was completed. LPN A stated she did not receive the chart back prior to her leaving for the day but passed the information to her relief nurse. An interview was conducted with CNA C on 6/20/24 at 3:23 p.m. CNA C stated she was not R601's aide that day but did respond to the radio for assistance in R601's room. CNA C stated, when she got to R601's room, LPN A and CNA B were observing R601 who was lying on her left side facing the door into the hallway. CNA C stated she did not observe LPN A complete any post fall assessments and requested CNA B and CNA C place R601 back into her bed. CNA C confirmed they did place R601 back in bed with a gait belt, lifting and sliding her to the bed and hoisting her back. CNA C confirmed they should have used a mechanical lift to place R601 back into bed and did not receive further education on how to transfer a resident post fall. An interview was conducted with the Director of Nursing (DON) on 6/20/24 at 4:12 p.m. The DON confirmed she was working as a floor nurse on 5/20/24 along with LPN A. The DON stated it was LPN A who placed R601 into her wheelchair and placed the footrest in an elevated position because she was annoyed with the requests R601 was making. The DON stated she instructed LPN A to complete a bladder scan on R601, but LPN A refused. When the DON saw R601 after her fall, she confirmed R601 had to have attempted to stand from her recliner and her elevated footrest launched her onto the floor. The DON stated, according to witness statements, LPN A instructed the two CNAs to put R601 in bed and did not complete a post fall assessment and did not order for an x-ray per the physician order. An interview was conducted with R601 on 6/20/24 at 4:30 p.m. R601 was observed sitting in a recliner geri chair. R601 stated she fell a while back and continued to have pain from the fall. R601 could not explain further how she fell. Review of the termination record for LPN A read, in part, Termination 5/31/24; Violation Information; 5/20/24 Gross negligence and/or gross misconduct in the performance of duties. Violation of accepted professional standards pertaining to patient care and technical practices or ethics. Details of what occurred: On 5/20/24 you were assigned to perform a bladder scan and assist (R601) into bed due to her discomfort and restlessness. You were also asked to reach out to the doctor for a PRN (as needed) medication for anxiety as you said you had already given the resident something for anxiety that did not work. Upon investigation it was noted she did not have any PRN anxiolytic medications. Regrettably, it has come to our attention that you did not lay the resident down, which may have contributed to her falling. Furthermore, your decision to restrain the patient by putting her feet up potentially led to a distressing incident where the patient fell and sustained a hip injury. Despite the gravity of the situation, your failure to promptly follow through with the necessary verbal and written X-ray orders to rule out hip, knee, and pelvis fractures on the day of is deeply concerning. This lapse in providing essential medical care has led to a breach of our duty to ensure patient safety and well-being. Your initial explanation, citing a lack of awareness regarding the order for the X-ray, followed by a claim of incompetence in executing orders, reflects a pattern of inadequate communication and competency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers to intake(s): MI00139977 Based on interview and record review, the facility failed to implement appropriate interventions to prevent a fall for one Resident (R2) of three residents reviewed for falls. This deficient practice resulted in R2 sustaining a fall with subsequent injuries requiring staples. Findings include: R2 A review of R2's electronic medical record (EMR) revealed admission to the facility on 9/18/23 with diagnoses including repeated falls, weakness, osteoarthritis, pain, and dementia with behaviors. R2 scored a 7/15 on the 9/25/23 Brief Interview for Mental Status (BIMS) score indicating he was severely cognitively impaired. In Section J on R2's 9/25/23 Minimum Data Set (MDS) assessment he was marked 'yes' as having a fall in the last month prior to admission/entry into facility. R2's Fall Risk Assessment Tool dated 9/18/23 revealed he scored an 18, indicative that he was a high fall risk. Review of R2's Care Plans revealed the following: Problem Start Date 9/18/23, Category: Falls: At risk for falls related to impaired cognition, weakness, and fall history while at home .Approach Start Date: 9/18/23 Ensure (R2) has a floormat in place next to his bed at all times when in bed. When in wheelchair the floor mat may be stored in the closet .Approach Start Date: 9/18/23 Ensure (R2) has grippy socks or footwear with grippy soles for safe ambulation and transfers .Approach Start Date: 9/18/23 Ensure call light is within reach at all times when (R2) is in the room .Approach Start Date: 9/18/23 Ensure walkway is well lit and free from clutter and spills .Approach Start Date: 9/18/23 Keep bed at lowest height when not providing cares .Approach Start Date: 9/18/23 Pad alarm to bed, wheelchair, & bedside chair (if applicable). Check alarm placement, low battery indicator, and functionality of both pad & alarm box, prior to leaving (R2) unattended . A review of R2's Fall Investigation Summary dated 9/29/23 read, in part, At approx. (approximately) 9:50 a.m. resident fell. (Certified Nurse Aide [CNA] I) found him on the floor (resident was attempting to get up) and called the nurse. Nurse (Registered Nurse [RN] F) entered the room and found resident sitting on the floor .Resident told the aide and nurse his feet got tangled in the sheet and he fell. Shortly after (RN D) entered the room and resident was in bed .At the time of the fall resident stated his scalp hurt but denied all other pain. EMS (Emergency Medical Services) was called per physician order to send to the ER (Emergency Room) for treatment. Per report from the hospital resident received 4 staples to the injury which was noted by the nurse 2 cm (centimeters) x 3 cm. Resident was difficult upon return from ER yelling out. CAT (Computerized Axial Tomography) scan completed no findings .The Admin (Administrator) and DON (Director of Nursing) found that resident had been moved earlier in the day. (RN D) had noted she had checked his bed and chair alarms, low bed, and mat in place on the clinical chart however she stated in her progress note that certain items were not in place .The nurses are tasked with a check off system in the electronic chart to ensure that all interventions are in place. The nurse stated she had ensured all was in place at 7:30 p.m., but at the time the fall happen [six] she stated these interventions were not in place . Review of R2's Emergency Department - Final Note dated 9/29/23 read, in part, .Physical Exam, Head: 5 cm scalp laceration on the occiput .Patient does appear to have a scalp laceration which will require repair .After copious cleaning with sterile saline four skin staples were applied . Review of CNA I's witness statement dated 9/29/23 read, in part, Did you witness the fall? No .Was the alarm going off and if so what type of alarm, bed/chair? No alarms were on bed, Resident was moved to this room when alarms should have been placed .Had the resident or could the resident tell you what happened? Yes, resident said his feet got tangled up in his sheet. Review of RN D's witness statement dated 9/29/23 read, in part, .Resident was transferred 9/29/23 from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-1. Resident was in w/c (wheelchair) @ (at) shift change with active w/c pad alarm. There was no bed alarm or mat in the room . An interview was conducted with the Administrator on 1/31/24 at 3:00 p.m. The Administrator confirmed that the fall mat and bed alarm were not in place at the time of R2's fall on 9/29/23. The Administrator stated that the resident had been moved earlier that day, and that the nurse checked that all interventions were in place when they in fact were not. Review of the facility's Falls-Clinical Protocol policy revised in March 2018 read, in part, .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake number: MI00144208 Based on interview and record review, the facility failed to follow the physicians order for PT/INR (prothrombin time/international normalized ration) laboratory testing for one Resident (R4) of three residents reviewed for physician orders. This deficient practice resulted in a delay in treatment in response to R4's blood work which subsequently resulted in R4's hospitalization. Findings include: R4 Review of R4's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including cerebral infarction, and paroxysmal atrial fibrillation. R4's 11/2/23 Brief Interview for Mental Status (BIMS) score was 3/15 indicative of severe cognitive impairment. Review of R4's Minimum Data Set (MDS) assessment dated [DATE], revealed in Section N0415, High Risk Drug Classes, R4 was marked as taking anticoagulant medications. Review of R4's Baseline Care Plan dated 10/26/23 read, in part, .Medications: Anticoagulant: Coumadin .Lab monitoring: yes . Review of R4's Physician Note dated 10/26/23 and written by Medical Doctor (MD) J read, in part, .History of Present Illness: .present to [facility name] hospital September 27, 2023 being discharged home on October 2, 2023 post treatment for an acute urinary tract infection, atrial fibrillation with RVR (rapid ventricular response[bottom heart chambers beating too fast]) and a subacute right sided subacute infarction with left-sided weakness and dysphagia .medications were adjusted during hospitalization and she was discharged home .and resumed Coumadin therapy .It is unclear when her last pro time INR was completed .discharge from hospital pro time 14.5 INR 1.12 .Diagnosis, Assessment and Plan: Paroxysmal atrial fibrillation: .She has been placed back on Coumadin 5 mg (milligrams) daily. I have ordered a pro time, INR, and CBC (complete blood count) to be drawn next lab day. Currently there is no evidence of concern with anticoagulation. Cerebrovascular accident (CVA): Pro Time INR along with CBC (complete blood count) has been written for and I have requested results of her hemoglobin A1c (blood sugar average 90 days) and lipid panel. Medical non-compliance: education provided to her during this visit about the need to be compliant with medications and follow-up both for blood work being on Coumadin and her primary care provider appointments. Multiple bruises: monitor closely. I suspect this is a combination from blood work and IV sites during hospitalization and falls while at home along with anticoagulation on Coumadin. I have ordered blood work including a pro time INR and CBC along with TSH (thyroid stimulating hormone), B12 and folic acid and will adjust medications and treatment depending on results. Review of R4's Physician Telephone Orders dated 10/26/23 and signed by MD J read, in part, Tues (10/31/23): PT/INR, CBC. BMP, Mag, Vit (vitamin) D, TSH, B12, Folate, HA1C, Lipid Panel. This was also signed by two facility nurses, indicating they received and entered the order into the computer system. The two nurses were confirmed to be Licensed Practical Nurse (LPN) G and Registered Nurse (RN) D. Review of R4's Physician Noted dated 10/27/23 and written by Physician Assistant (PA) C read, in part, .(R4) has a history of atrial fibrillation and was on warfarin (also known as Coumadin) .she was lost to INR follow-up since March 2021 on the date of her last visit .Diagnosis and Assessment: Paroxysmal atrial fibrillation; patient is to be on Coumadin. She will need her INR . Review of R4's EMR Medication Administration Record (MAR) revealed that MD J's order for labs was entered into the computer to be drawn on Tuesday October 31st, 2023. It was noted that RN K wrote on 10/31/23 at 2:07 p.m. in R4's MAR Not Taken .Late Administration: Charted late . Review of R4's Physician Note dated 11/1/23 and written by PA C read, in part, .I was asked to urgently evaluate patient by staff. Staff attempted to perform a phlebotomy and patient abruptly became extremely pale and quite unresponsive .Patient is extremely pale and cool. Some clamminess has. Patient had a recent passage of large amounts of blood clots in urine. Patient has been here since the 27th and we have no PT INRs. Patients' family was contacted, and we will send to the hospital for further evaluation .Patient has not had PT/INR since admission . Review of R4's Progress Notes dated 11/1/23 and written by Licensed Practical Nurse (LPN) L read, in part, Resident returned to facility via EMS, lab work at hospital showed PT 116.9 INR 15.32 [Critical] (Normal Range INR: 2.0-3.0) she was treated with vit K and IV fluids. She was seen at her PCP (primary care provider) office on 10/12/23 for admission to [facility name] her admission orders from that visit called for 5 mg of coumadin daily, however her son said that the PCP office had called them 'a couple days later' and changed her to 2.5 mg daily however that was not communicated to us by her PCP office prior to her admit her on 10/26/23 . Review of R4's Physician Noted dated 11/2/23 and written by PA C read, in part, .Family noted that she had a progressive weakness and has a large amount of blood in the urine this morning discovered by [facility name] employees .patient had PT/INR which showed INR greater than 15.32 which was critical. Patient then had 1 L (liter) of normal saline IV (intravenous) along with vitamin K 10 mg (milligrams) IV piggyback. Patient is to hold Coumadin x (times) 3 days and then have a recheck of PT/INR .Diagnosis and Assessment: Poisoning by anticoagulant antagonists, vitamin K and other coagulants, accidental (unintentional), initial encounter . An interview was conducted with PA C on 1/31/24 at 11:15 a.m. PA C confirmed that a physician order was written for R4 to have a PT/INR drawn on 10/31/23, and that the order was not completed by staff on 10/31/23. PA C then stated, had the PT/INR been drawn on the correct date, staff would have had time to respond and adjust R4's medications as needed. During a follow up interview on 1/31/24 at 1:50 p.m. PA C was asked about how physician orders are written and communicated to the facility staff. PA C stated that orders are written on a tri-colored sheet and then entered the EMR system for each specific resident by the facility nursing staff. An interview was conducted with the Director of Nursing (DON) on 1/31/24 at 2:15 p.m. The DON stated that physician orders are reviewed and entered into the facility's EMR system and then left open for a second nurse to verify and close out each physician order. When asked why R4 did not receive a lab draw on 10/31/23 per physician order, the DON stated that it was verified and entered by two nurses per the facility protocol and could not explain why it was not drawn on 10/31/23. An interview was conducted with the Nursing Home Administrator (NHA) on 1/31/24 at 3:00 p.m. The NHA confirmed that there was a system failure for R4, related to her lab draws that were to be completed on 10/31/23. The NHA stated that R4's labs were not completed on that day when they should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate safety and supervision to prevent a fall with major injury for one Resident (#1) of three residents reviewed for falls. This deficient practice resulted in actual harm to Resident #1, who sustained cervical (neck) fractures, a functional decline, and increased pain. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 10/18/22, showed Resident #1 was admitted to the facility on [DATE], with diagnoses including anemia, kidney disease, diabetes, and hyponatremia (low sodium/electrolyte imbalance). Resident #1 required one-person assistance for dressing, transfers, and toileting, and supervision for walking in their room and for wheelchair mobility. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed Resident #1 had normal cognitive impairment. The assessment showed Resident #1 wore glasses, and there was no sensory impairment (vision, hearing, speech, understanding), and no behaviors. Review of the facility's 5-day Investigation report, dated 12/14/22, revealed on 12/06/22: Resident #1 returned from the Emergency Department (ED) with Acute C5, C6, and C7 (Cervical/neck vertebrae) spinous fractures, acute posterior head contusion (bruise), and acute thoracolumbar (mid-back muscle) strain . The report reflected Resident #1 was not admitted due to reasonable pain control and stable C-spine fractures. A rigid neck collar was placed at time of fracture, to use as needed, with a soft roll neck collar to be worn after. Additionally, on 12/07/22, Resident #1 was admitted to the hospital with a GI (gastrointestinal) bleed, with no additional intervention recommended, and it was noted the neck fracture remained stable, with soft collar again recommended. Per this report, the neck fractures occurred when Resident #1 fell off the wheelchair lift on the facility transport van, which had parked at a community restaurant during a facility outing. This occurred when the Van Driver, Staff A, was pushing [Resident #1]'s wheelchair backwards out of the van onto the lift, when [Staff A] realized the lift was not in the 'up' position, and despite her attempts, [Staff A] was unable to stop [Resident #1's] wheelchair, and unfortunately, they [Resident #1 and Staff A] both fell out of the van, and were taken to ER via ambulance .[Resident #1] obtained C-spine fractures, and [the] driver obtained [sic] hand fractures . The report showed there were three residents in the van, and when the Activity Coordinator (Staff B) had taken Resident #2 off the lift, they left the lift on the ground, and had not raised it to the 'up' position and the accident ensured . The report revealed, .[Resident #1] experienced some pain due to the trauma of the fall .Corrective actions taken: When two staff are present during transports it has been common procedure to have one staff member handle the resident(s), and the other staff member handle the lift controller. We believe this may have contributed to the fall. Therefore, we have determined to ensure this accident does not recur, the procedure will be going forward only the van driver [chauffeur] will move the patients on and off the lift and utilize the lift controller to raise and lower the lifts . Abuse and neglect were ruled out by the facility, and nothing intentional was found on the part of staff. During an interview on 12/28/22 at 10:30 a.m., the Nursing Home Administrator (NHA) was asked about the incident. The NHA confirmed the incident occurred as described above. The NHA was asked about a facility process describing the steps to transporting and securing a resident in the facility transport van with lift, and confirmed there was no process delineating each step, as the steps were right on the van posted adjacent to the lift. The NHA reported Staff A's vision had been checked, and there were no vision or health concerns. The NHA reported upon investigating there had been some distractions, as Staff A had been discussing the resident's lunch order (for the restaurant) during the process. The NHA explained Staff B was not a chauffeur, and had pushed the button (lift controller) to lower the lift, and had stated, I was trying to help. The NHA confirmed both Staff A and Staff B were involved in a process failure related to human error, verses any concerns with the van or lift apparatus, and the van had just been in for service the month prior with no concerns. When asked about Resident #1, the NHA confirmed Resident #1 had cervical fractures after the fall, and her glasses were broken, and clarified Resident #1 was not fearful after the incident or since. The NHA confirmed this was an accident, not neglect or abuse, and reported Staff A was taken off transport that day, had not worked in transportation since, and was wearing a cast due to an arm fracture, which Surveyor observed. The NHA reported the four transporters had received an immediate education that they were the only staff responsible for taking residents in and out of the transport van and operating the wheelchair lift/ramp. The NHA confirmed Staff A and Staff B made the decision to take three residents with two attendants, as the residents were independent in wheelchair mobility at the facility, and there was no process or policy that said there had to be one attendant per chauffeur, yet this was typically done. The NHA reported it was up to activities coordinator and chauffeur to make the decision of how many residents to take on outings, given available staff and needs of the residents, and confirmed they supervised the transportation supervisor (Staff A) and staff, including the chauffeurs. Review of Resident #1's ED Final Report, dated 12/06/22, revealed, This [AGE] year old female [Resident #1] presents with her aide [Staff A] .The aide was getting [Resident #1] out of wheelchair van and was pushing [the] wheelchair from the front .[Staff A] thought the ramp was down but apparently it was not, and she [Staff A] pushed the wheelchair backwards and obviously the patient [Resident #1] then fell back and the aide went with her .[Resident #1] hit the back of her head, and presents with pain in the head but also throughout her spine. She did not lose consciousness .CT head: no intracranial hemorrhage .CT-spine: Impression: Acute fractures through the spinous process of C5, spinous process and left lamina of C6, and spinous process and bilateral lamina of C7 . Compression fractures and stenosis of the thoracic [mid] spine were noted, This [AGE] year old female suffered an accident when getting pushed out of her transport van. [Resident #1] ended up falling backwards, hitting the back of her head and suffering what I would assume is a hyperflexion injury of the C-spine .X-ray did not show any traumatic changes in the thoracal lumbar spine [sic] did not show anything acute but she [Resident #1] does have some old severe compression fractures of the thoracic spine .CT spine was reviewed .these are basically advanced spinous process fractures [sic] .they are felt to be stable and even C-spine immobilization is based on patient's preference and comfort. Patient was given IV [intravenous] [name brand over the counter pain medication] along with a single dose of [a name brand prescription pain relieving medication] .There is no indication for admission at this time based on reasonable pain control and her stable C-spine fractures. We will send her home with [Brand name of rigid fixed neck] collar to use as needed. I also recommend getting a true soft roll [neck] collar .Diagnosis: 1. Acute C5 spinous process fracture. 2. Acute C6 spinous process and left lamina fracture. 3. Acute #7 spinous process and bilateral lamina fractures. 4. Acute posterior head contusion [bruise], 5. Acute thoracolumbar [thoracic spine] strain .Disposition: Discharge home [to nursing facility] . Review of Resident #1's [hospital] Patient Education Material, titled, Spinous Process Fracture, revealed, a fracture of a spinous process is a break of a part of one of the bones in the spine. This part extends out from the back of the main body of the bone (called the vertebral body) .In the elderly, these injuries can also occur in the lower neck area .It takes a lot of force to cause this type of fracture .Most of these injuries occur as a result of a variety of accidents such as: Falls .Patients with process fractures have severe pain even if the actual break is small or limited .Medication for pain control, special back bracing, and limitations in activity are done first followed by physical therapy later . Review of Staff A's witness statement, dated 12/06/22, revealed, Tuesday, December 6th at 12:30 p.m., [Staff B], Activities Coordinator, 3 residents, and myself went on a resident outing to lunch and Christmas shopping at [local retail store]. I loaded the three residents, one of which was [Resident #1], into the facility lift van. Upon arrival at the lunch destination, I removed the safety straps on the first resident and rolled resident [#2] onto the exit lift from the inside of the van. [Staff B] was on the outside of van and lowered the lift to the ground and assisted the resident into the restaurant. Meanwhile, I [The Admissions Coordinator, Staff A] removed the safety straps from [Resident #1]'s wheelchair and [sic] pushing her to the exit lift with her back to the exit. I thought the lift was raised and was in place. At the last second, I realized the lift was not raised and despite my attempts I [Staff A] was not able to stop [Resident #1]'s wheelchair and unfortunately both [Resident #1] and I [Staff A] fell out of the van. [Resident #1] landed on her back and I landed on top of her side and pavement. 911 arrived. We were both taken to ER [name of the local emergency room of nearby hospital] .I have been working at [Facility] for 26 years and am responsible for scheduling and transporting the residents to appointments and outings. We have never had an accident while transporting our residents. The NHA confirmed this as accurate. Review of Staff B's Witness Statement, dated 12/07/22, revealed, On 12/06/22, [Staff A] and myself planned an outing for three of our residents. [Staff A] loaded and secured the three residents in the transport van for lunch and shopping .I [Staff B] lowered the lift and assisted the first resident off [Resident #2]. [Resident #2] is able to self-propel in her wheelchair but was having difficulty on the slight incline [pavement]. Trying to be helpful, I [Staff B] left the back of the van to assist the resident [Resident #2] into the restaurant .We were inside when I heard [Staff A] yell .I went back outside to find [Resident #1] laying on her left side on the lift. [Staff A] was sitting beside her also on the lift. A bystander was already on the phone with 911 . Review of Resident #1's Witness Statement revealed, .Describes in detail how [Staff A] pushed her from in front of her to lift that evidently wasn't there. 'All of a sudden I was falling backwards and [Staff A] fell with me .The doctor said I had neck fractures' . Review of Resident #2's witness statement revealed, [Staff B] helped me down on the lift. When [Staff B] was wheeling me away, she turned to [Staff A] and said, 'I'll be right back to help you with [Resident #1] .[Staff B] went back out to get [Resident #1] and came running back in for help. [Staff B] told me, 'There's been an emergency.' [Staff B] went back outside but came back in to check on me . During an observation on 12/28/22 at 1:10 p.m., Resident #1 was observed in their room, and agreed to be interviewed. Resident #1 was wearing her soft neck collar, and propelled her wheelchair to the doorway approximately 5', and then asked for staff assistance to wheel her out of room down the hallway to be interviewed in a private area in the facility per her preference. Resident #1 reported she experienced moderate neck and back pain when pushing her wheelchair. During an interview on 12/28/22 at 1:20 p.m., Resident #1 reported the incident occurred on a Tuesday this month, before Christmas, and described how she and two other residents were in the wheelchair van with lift for an outing, and they took a bigger van to fit the three residents. Resident #1 stated, [Staff A] thought [Staff B] raised the ramp up, and [Staff B] didn't, and it was still on the ground, and she [Staff A] started to push me out, and I [Resident #1] went head over heels out of the van, and [Staff A] fell on top of me. Resident #1 described how she went out backwards, and Staff A came out frontwards, and Staff A broke her arm, and added, My back was hurting like crazy, all the way through my back. Resident #1 reported they were both taken to the hospital, and she was told she had two broken bones in her neck, and was given a hard neck collar to wear two days and then the soft collar which she was currently still wearing, and had to wear it for six weeks. Resident #1 reported she felt scared when the incident happened, and stated, I feel ok now. I tell [Staff A] not to worry as it was an accident . Resident #1 confirmed nothing was intentional and there was no abuse, and [Staff A] was distressed the incident had occurred. Resident #1 reported her family (responsible party) believed Staff A should have looked (before pushing Resident #1 out of the van), and it should not have happened. During further interview, Resident #1 was asked about the subsequent hospital stays for a GI bleed and low blood pressure related to medications. Resident #1 reported she had incidents of blood in her stool prior, and did not believe this hospital visit was related to the fall on 12/06/22. When asked about pain, Resident #1 reported she did not have neck or back pain prior to her fall, and described the pain initially as all over my back, and stated, I am starting to get better. When asked about her prior functional level for self-care and mobility, Resident #1 reported she used her walker to go to the bathroom, and go to bed, and used the wheelchair in her room prior, and said, I'm using the wheelchair now, and reported it was physically difficult to propel the wheelchair (herself) at times since the accident. Resident #1 described her mood as happy and she felt safe at the facility and was receiving good care. Regarding pain, Resident #1 denied neck pain during the interview, and reported constant pain in her back ranging from 5/10 (with 10 the highest pain level) to 9/10. Resident #1 reported she did not believe the pain medications were adequately controlling her pain, and would like additional pain medication (which was shared after the interview with nursing management, the physician, and the NHA). When asked to show Surveyor where pain was occurring, Resident #1 reached back to the lower left side of her back (thoracic/lumbar region -mid to low back). Resident #1 expressed frustration she was not able to do more for herself, and explained prior to the fall she used to dress herself when staff obtained her clothing, and she would get herself to the bathroom and onto the toilet, and staff assisted her off of the toilet. Resident #1 stated, I have told my friends it is frustrating they [staff] have to wait on me. Resident #1 asked how long she needed to wear the neck brace, and described how it was very irritating (the soft neck collar), as she had to sleep and eat with it. When asked about activities, Resident #1 reported while she was participating, she needed additional assistance, and was upset her gingerbread house [holiday project] fell apart, which she could have completed prior to the incident. Resident #1 added while the social worker did see her once after the incident (which record review confirmed), she recognized she needed additional psychosocial support, as she was feeling frustrated by the neck brace and the functional decline and needing assistance with some activities. Surveyor notified nursing management and the NHA of Resident #1's request for additional psychosocial supportive visits. During the interview, Resident #1 was fully oriented and demonstrated good cognition including sequential recall of the incident, subsequent hospital visits, and described medical interventions. A phone call was made to Resident #1's family member/responsible party on 1/03/22 at 11:07 a.m , which identified them as the recipient of the voicemail. No call was returned by the end of the survey. During an interview on 12/28/22 at 2:37 p.m., the Activity Coordinator, Staff B confirmed the incident on 12/06/22 occurred, and they left the facility van lift (platform) on the ground, when Resident #2 needed assistance to propel herself into the restaurant. Staff B reported they were newer to their position as activity coordinator (since April, 2022), and had not been trained in the use of the facility van with lift. Staff B acknowledged this was only their third outing with residents (in the community), and said the other two times, The driver (chauffeur) did everything. Staff B reported they stepped in to help Staff A assist residents leave the van, but had not been asked. Staff B reported when they returned to the van they witnessed Resident #1 laying on her side, and Staff A sitting up next to her, both were on the lift platform, and a bystander called 911. Staff B acknowledged they did not have a chauffeur's license, and called the facility for assistance. Staff B reported they made sure the residents were safe, and called facility, who sent Staff F, another van driver, to assist with transport back to the facility. Staff B reported the prior activity director had not trained them on the use of the facility van and lift, and they had only participated and observed community outings when they used community transportation services. Staff B reported they had received an education after the accident with the chauffeurs regarding only the chauffeurs would secure residents in the wheelchair vans, apparatus, and lifts, and operate the lift themselves. During an interview on 12/28/22 at approximately 3:15 p.m., Health Care Coordinator, Chauffeur/Van Driver, Staff F, was asked about the process for operating the facility van with lift, and who was responsible for raising the lift up and down. Staff F reported the driver/chauffeur was responsible for the entire process of securing the residents in the vehicle, buckling seat belts, addressing tie downs, and raising and lowering the lift (platform). When asked how the accident occurred, Staff F reported both Staff A and Staff B were responsible, and Staff A would have been responsible for raising and lowering the lift. Staff F confirmed they were called to assist on 12/06/22 when the accident occurred, and they ensured Resident #2 and Resident #3 were returned safely to the facility, after they had received lunch, and brought Resident #1 lunch at the hospital. When asked about the number of residents (3) and the number of staff (2) on this outing, Staff B responded it is to the discretion of the chauffeur and activity coordinator to decide how many attendants were needed, and confirmed Resident #2 and Resident #3 had demonstrated independence with wheelchair mobility at the facility, and they would not have anticipated a concern. Staff F reported they would have independently done the whole process themselves as they always did, i.e. removing residents from the van, taking them to the restaurant, etc Staff F reported they received adequate training from Staff A and Staff C, had watched training video on the lift, and had return demonstrated use of the lift as part of their training. Staff F showed Surveyor their Chauffeur's license, which was current. Staff F reported both Staff A and Staff B were proficient at their jobs, and were valued employees at the facility, with no prior performance concerns related to transport or outings. During an interview on 12/28/22 at 3:48 p.m., Staff A was asked about the accident with Resident #1 on 12/06/22, related to the facility wheelchair van. Staff A confirmed the incident occurred, and indicated Resident #1 fell off the lift after Staff B had unloaded Resident #2, and Staff A was talking to Resident #1, and unfastened the clips securing the wheelchair to the van, and pushed Resident #1 'out', and thought the lift was there (in the 'up' position). As soon as Staff A noticed (the lift platform was still on the ground), they were both already on the ramp outside the vehicle, on the platform. Staff A placed the wheelchair pad under Resident #1's head, and an observer called 911. Staff A reported Resident #1 did not lose consciousness, and stated, I just hurt. Staff A reported their face was bleeding. Staff A described they observed Resident #1 laying on the metal lift platform on the side over the edge, and was located between the ground and the lift, and was positioned on her side. Resident #1 reportedly denied hitting her head at the time. When asked how this accident could have been prevented, Staff A stated, I should have taken full responsibility for the lift. Staff A reported they and chauffeur staff had been reeducated only the driver will control the lift. Staff A reported they had been using the van and lift and acting as a Chauffeur for over 5 years, and had never had an accident or incident using the van or lift, nor had any of the van drivers/chauffeur's, which the NHA earlier confirmed. Staff A reported the prior activities coordinator and herself had both used loaded and unloaded residents from the van (in the past), and they were not aware Staff B had not been trained in this process. Staff A reported both they and Staff C trained the chauffeurs, and the activity coordinator (former) would have trained Staff B in their job duties. Staff A denied any personal factors contributing to the fall, such as vision, health, being under the influence of substances, or other concerns. Staff A reported there was no intent, and they felt very bad about the accident. Staff A acknowledged they were distracted both by talking to Resident #1 as they were unbuckling them, and by Staff B assisting with the lift process. Staff A confirmed they had received adequate training on the use of the facility van with lift, and trained staff in its use, along with the Van Driver, Staff C. Surveyor attempted to interview Residents #2 on 12/28/22 at approximately 2:00 p.m., and on 1/03/23 at 10:10 a.m Resident #2 declined to be interviewed due to upcoming activities, and was out of the facility at a doctor appointment, respectively. During an interview on 1/03/23 at 10:27 a.m., Certified Nurse Aide (CNA) K was asked about Resident #1's functional status prior and post the accident (fall off van lift on 12/06/22). CNA K explained prior to the accident Resident #1 would walk to the bathroom herself, mainly toileted herself, dressed herself overall, but needed minimal assistance for lower extremity dressing, required stand by assistance for transfers, and propelled her own wheelchair in her room. CNA K clarified at present Resident #1 frequently declined to push her own wheelchair due to pain. CNA K stated Resident #1 was attending activities regularly, however, was sleeping more, often sleeping in until noon, when prior she was up earlier in the morning. CNA K reported no change in Resident #1's affect, reporting she was generally happy, was not fearful or anxious, and had no falls since the occurrence. Review of the Risk Management Occurrence Reporting Worksheet, for Resident #1, received from the Nursing Home Administrator (NHA), dated 12/06/22, revealed, Resident [#1] Fell out of the wheelchair van backwards, hitting head. Transporter [Staff A] fell on top of her. Transporter has been pulled from transporting/lift operating until proper investigation can be completed. Resident [#1] went to ER for evaluation. This form showed notification of physician, family member, and NHA. Review of Resident #1's nursing progress note, dated 12/06/22 at 10:19 p.m., revealed Resident #1 returned to the facility at approximately 8:15 p.m., wearing a neck collar for stabilization and comfort, and she could remove or wear as needed. A prescription for Naproxen [a pain medication with anti-inflammatory properties] was included, with diagnosis Stable cervical spine fractures [C5 - C7] .Resident had small abrasions on left elbow and left knee. Resident [#1] in pleasant mood but stated she was sore . Review of Resident #1's nursing progress note, dated 12/07/22 at 11:02 p.m., revealed, Called [hospital] ED to get an update on [Resident #1] .Admitting diagnosis of GI bleed, not suspected due to 12/06/22 event [fall with cervical fractures] . Review of Resident #1's Medication Administration Record (MAR) for December, 2022, revealed Resident #1 had [an OTC - Over the Counter pain medication ordered in the dose 500 mg every 6 hours PRN (as needed). Resident #1 received one dose on 12/06/22, prior to being hospitalized with a GI bleed on 12/07/22. She did not utilize any of the Naproxen ordered after the fall. Review of Resident #1's Physician Visit note, dated 12/20/22, revealed, [AGE] year-old female [Resident #1] with multiple comorbid conditions was initially admitted to [Name of] Hospital. She apparently fell while getting out of a transport vehicle. There was obvious head and neck injury .Imaging studies .were remarkable for acute C5, 6, and 7 spinous process fractures, chronic [ongoing/past] T6 and T9 compression fractures, and diffuse degenerative changes throughout patient's spine. The patient was placed in a C-collar [Cervical Collar]. Neurosurgery was consulted. It was felt the patient's fractures were stable and conservative management was recommended. [Resident #1] was subsequently discharged back to [facility]. On 12/07/22, the patient had gross blood in her stool. She was transferred back to the emergency room .Admitting hemoglobin was stable. She was subsequently admitted for a GI bleed. Given the patient's stable hemoglobin, outpatient evaluation was recommended . A third hospitalization was described on 12/14/22, for an apparent medication reaction, and two of Resident #1's pain medications were discontinued (Norco and a muscle relaxant). Resident #1 continued to report neck pain upon readmission, and inadequate pain control was noted. It was recommended to continue Neurontin (a medication which addressed nerve pain), increase Tylenol and Ibuprofen coverage (dosing), and add Tramadol (a controlled pain medication) as needed. The report showed Resident #1 had a long history of GI concerns; labs were ordered and an outpatient GI follow up was scheduled. Review of Resident #1's Physician Visit note, dated 12/29/22, revealed, Reevaluation of this [AGE] year-old female with multiple comorbid conditions who was placed on tizanidine and Norco for both muscle spasms and pain control on follow-up visit, December 12th (2022). On the morning of December 14 (2022), she had been provided with both her first dose of tizanidine 4g along, with Norco 5/325 mg, and subsequently was found unresponsive with low blood pressure . The report showed resident became responsive prior to leaving the facility, and had elevated troponins (a possible indication of heart damage) at the hospital however there were no acute EKG (heart monitor) changes and echocardiogram (heart ultrasound) was done and showed no changes as well. Thus Resident #1 was deemed stable and returned to the facility. During another physician visit on 12/20/22, Resident #1 had increased pain in her cervical region and low back. A history of chronic pain was noted with diabetic polyneuropathy (nerve pain throughout body) and chronic low back pain. She had been sent back from the hospital with Tylenol only and as needed use of cervical collar. Physician ordered Ibuprofen and tramadol at that time, which Resident #1 reported was causing her nausea and increasing her acid reflux. During Physician Is evaluation on this visit date (12/29/22), Resident #1 reported her pain was not in her neck but in her low back. Physician I added a prescription pain medication patch and a medication to help the bone healing, as well as warm blankets, and a second OTC (over the counter) pain patch, and keeping the Tylenol and gabapentin in place as needed. During this same physician visit, Resident #1 expressed not wanting to wear the cervical collar, as it was restricting her activities. Resident #1 agreed to wear 4 to 6 more weeks per Physician I recommendation, only if she could remove for meals and sleeping; Physician I respected resident wishes per her strong insistence. This report noted Resident #1 reported her social activities had significantly deteriorated since the time of her fall. Physician I noted and observed Resident #1's activity and activities of daily living participation had significantly improved since the time of her fall, including pushing her wheelchair in her room, feeding herself, brushing her teeth and hair, with no pain or grimacing, stable range of motion, sleeping well, and reportedly was ambulating in her room with assistance. Physician I noted the majority of Resident #1's pain was coming from her thoracic spine related to the (prior/old) compression fractures, and neurosurgical follow up was recommended for these concerns, and neurosurgery had not recommended follow up for the cervical spine, unless she was symptomatic. Resident #1 agreed to this appointment for back pain management. During a phone interview on 12/28/22 at approximately 4:25 p.m., Physician I was asked about Resident #1's medical status post the 12/06/22 incident (fall from van wheelchair lift). Physician I confirmed they were the primary physician overseeing Resident #1's care, and indicated the second hospitalization for the GI bleed was not related to the fall, as Resident #1 had GI concerns prior to the fall which were longstanding. Physician I reported Resident #1's cervical fractures showed no displacement, and they expected Resident #1 to make a full functional recovery, and added Resident #1 had old thoracic compression fractures, which were found with no change post the fall. Physician I indicated there had been pain medication changes for Resident #1 when they had been off work and there was coverage by another physician, and the reason Resident #1 was still experiencing pain was likely due to during her recent hospitalization she was taken off most of her pain medications, and was mainly receiving Tylenol, and had Tramadol (a pain medication) available, as she did not medically [NAME][TRUNCATED]