**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with hospital system's transportation staff (Driver #1), Passenger Services Manager and Nurse Practitioner (NP), the facility failed to leave Resident #45 in place for a clinical assessment of injury after a fall that occurred during transport. Resident #45 was being transported to dialysis in a hospital system owned transport van. Driver #1 made a sudden stop which caused Resident #45 to slide forward out his wheelchair onto the van floor when his seatbelt loosened. Driver #1 pulled the van into the median of the road and attempted to transfer Resident #45 back into his wheelchair. When Driver #1 was unsuccessful in transferring Resident #45 back to his wheelchair, she continued to transport Resident #45 to the dialysis center while the resident was seated on the floor of the transportation van. Driver #1 was not qualified to provide a comprehensive physical assessment to determine if the resident sustained any injuries. Resident #45 did not sustain any injury, however there was a high likelihood of serious injury after sliding out of his wheelchair onto the floor of the vehicle when the driver had to suddenly apply brakes to avoid hitting pedestrians. This deficient practice occurred for 1 of 3 sampled residents reviewed for quality of care (Resident #45). The immediate jeopardy began on 2/9/24 when Resident #45 was not physically assessed for injury before being moved and was transported to dialysis while seated and unsecured on the floor of the transportation van. The immediate jeopardy was removed on 10/15/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm that is immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: The Motor Vehicle Accident and Emergency Reporting procedure updated 6/23/23 included a policy that stated health care passenger service drivers would report a motor vehicle accident or medical/vehicle emergencies immediately. The supervisor should be called (number listed) to resolve any urgent or emergency situations concerning the driver, the delivery or pick-up of passengers, and vehicle related problems at any time. The procedures included if patient starts to slide or shift while in wheelchair during transport - driver must pull over when safe to do so and seek help. i.e. Call 911 - fire department, pull vehicle onto the shoulder of the road; assess patient and/ passenger to determine if emergency medical assistance was needed and if patient or passenger was injured, report this to your supervisor immediate so an online incident report can be done via CARE Event (A Care Event is an incident/accident report that involves resident safety). Resident #45 was admitted to the facility on [DATE] with diagnoses that included generalized weakness, end stage renal disease and hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #45 was cognitively intact. The MDS further indicated he required substantial/maximum assistance (helper does more than half of the effort) to go from a lying position to sitting, utilized a manual wheelchair and received dialysis. An interview was conducted with Resident #45 on 10/11/24 at 5:00 PM. Resident #45 stated he recalled an incident in which he slid from his wheelchair in the transportation van while going to his dialysis appointment. He further stated the brakes [when the driver applied brakes, it] threw him out of the chair. Resident #45 revealed he had gotten help from emergency medical service (EMS) staff to get back into his wheelchair. He stated Driver #1 slammed on brakes and he did not touch his seatbelt. Driver #1's witness statement dated 2/9/24 at 2:45 PM read Driver #1 was driving down [Highway] 52 South towards the dialysis center. Some pedestrians started to run out in the front of her and Driver #1 had to put on brakes suddenly. Somehow the seatbelt came loose, and Resident #45 slid out of wheelchair onto the floor. Driver #1 pulled into the median to check on Resident #45 and attempted to get him up. Resident #45 stated he wanted to stay there and just take him on to his appointment. Once at dialysis, Driver #1 asked for help from dialysis staff. The Dialysis Staff said they could only help if Resident #45 was visible in the building. Driver #1 called 911 to help. Resident #45 stated he was not hurt to the medic on the phone, and they came and got him back in the chair. Driver #1 took Resident #45 in dialysis center for his appointment. Interview with Driver #1 on 10/10/24 at 4:09 PM revealed she could not recall the date of the incident but recalled a van incident that occurred with Resident #45. She stated she was transporting Resident #45 to dialysis when she observed 2 pedestrians that appeared to be darting in the roadway. She slammed on brakes. When she slammed on the brakes, Resident #45 slid from his wheelchair, his seatbelt came loose and he landed on the van floor. She indicated it was the force of the van stopping that made the resident's seatbelt come loose and Resident #45 landed on the van floor. She stated she stopped the van and tried to put Resident #45 back in his chair. She could not get him in the chair, and he stated he did not want help. Driver #1 stated she was close to the dialysis center, so she drove Resident #45 while he was seated on the floor of the transportation van. She indicated she should have contacted 911 to get Resident #45 back into his wheelchair and not drive with him on the floor of the van. Following the incident, she received education to call 911 if a fall happened on transport and she shouldn't move a resident. She further stated she had seen the video of the incident as there was a camera on the transportation vans. An observation of video footage (visual and audio) of the van incident dated 2/9/24 was conducted with the Administrator on 10/11/24 at 2:31 PM. The video footage revealed a date of 2/9/24 and began at 11:43 AM. The camera was mounted in the front of the van and provided a view toward the rear of the van. Resident #45 originally seated behind the driver in the middle isle of the van. At 11:49 AM in transport, Resident #45 was observed to lean forward as his seatbelt was observed to come from his right side (where it was fastened) to his left. Resident #45 was observed to lean to his right side then slide forward out of his wheelchair in the aisle and then fall to his right. After falling to his right, Resident #45 was no longer visible through the video (behind passenger seat). His wheelchair could still be seen in the upright position. Driver #1 was observed to stop the transportation van in the road's median and stated someone ran out in front of her. Driver #1 then exited the driver's seat and entered the side door of the transportation van. She was overheard to tell Resident #45 You going to have to help me out now. Resident #45 was heard telling Driver #1 she was going to have to get some help. Driver #1 was observed to attempt to get the resident back up into his wheelchair as evidenced by picking him up under both arms. Resident #45 was observed sliding back out of his wheelchair back onto his bottom to the floor of the transportation van. Driver #1 then positioned Resident #45's back against his wheelchair while he was seated on the floor while telling him to hold on. Driver #1 was further observed to get back in the driver's seat. She stated she would drive slow. She also stated Resident #45 shouldn't have taken his seatbelt off. Driver #1 transported Resident #45 to the dialysis center. At 11:53 AM Driver #1 was observed pulling into the dialysis center parking covered parking deck. Resident #45 could be heard breathing heavy and moaning. Driver #1 was observed to go into the dialysis center, and then shortly after came back out to the transportation van. Within distance of the surveillance video, Driver #1 was observed to make a phone call at 11:55 AM (not within distance to overhear conversation). Driver #1 was observed to meet emergency medical services (EMS) upon arrival at 12:08 PM. Two EMS personnel were observed to assist Resident #45 back into his wheelchair at 12:10 PM. EMS were observed not to take vital signs or check Resident #45 for injuries. After EMS transferred Resident #45 into his wheelchair they exited the transportation van. Driver #1 was observed taking Resident #45 into the dialysis center at 12:12 PM. According to contact with the local EMS agency on 10/22/24, a report was not made. EMS attendants observed in the video footage did not document the event. Interview with Passenger Services Manager on 10/11/24 at 2:00 PM revealed when an incident occurred during transport, the driver should contact dispatch office. After watching the video footage she indicated following the incident, Driver #1 should have contacted 911 to assist her transferring Resident #45 back into his wheelchair. Driver #1 should not have attempted to transfer Resident #45. She indicated that due to the investigation, Driver #1 was reeducated regarding the seatbelt strap, transporting a secured resident and contacting 911 for assistance. She further indicated it was not part of the procedure to drive with a resident on the floor of the van unsecured. On 10/14/24 at 9:03 AM the Unit Manager stated she had not completed an incident report for the fall but did put the incident in a care event. She continued that generally, when a resident had a fall, the facility would assess the resident before moving them. Assessing the resident prior to getting him up was to ensure there were no fractures or anything that could cause more damage if moved. Interview with the Nurse Practitioner on 10/14/24 at 11:00 AM initially indicated she did not believe the resident had the dexterity to unhook his seatbelt. She stated there should be an assessment of the resident before he was assisted up from the floor of the transportation van. The assessment would have included his level of consciousness, a quick neurological check to see if moving all extremities, baseline mentation, looking for trauma, blood, bruising or any signs of injury. A body assessment should have been completed to identify any abrasions that could have occurred due to the incident. Resident #45 was not someone who could be lifted because Resident #45 cannot assist. An interview with Director of Nursing Services, on 10/14/24 at 3:26 PM was conducted. She stated she had seen the video of the incident involving Resident #45 while he was being transported to his appointment. She further revealed Driver #1 would not have been able to assess the resident due to not being licensed. She indicated Driver #1 also continued to transport Resident #45 following the fall while he was seated on the floor of the transportation van. Driver #1 should have contacted 911 for assistance. Interview with the Administrator on 10/14/24 at 2:12 PM stated she was not clinical and was not involved with Resident #45's assessment following the incident Driver #1 should have not attempted to pick up Resident #45 from the floor of the van and should not have continued to transport Resident #45 while seated on the floor of the transport van. Resident #45 should be assessed before he was moved, and she assumed EMS would have assessed him. The facility was notified of immediate jeopardy on 10/11/24 at 7:17 PM. The facility provided the following immediate jeopardy removal plan. Identify those recipients wo have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 2/09/24 Resident #45 was at the dialysis clinic when the Administrator was notified by a staff member that Resident #45 experienced a fall while in van transport. Driver #1 did not notify the facility administrator nor her supervisor, the Passenger Services Manager, about the accident. On 2/09/24 the Administrator contacted the Passenger Services Manager to begin an investigation and require education of Driver #1. On 2/09/24 Driver #1 put on the brakes suddenly and Resident #45 slid from his wheelchair onto the floor. Driver #1 stated that she did attempt to get Resident #45 up however Resident #45 stated to just to leave him on the van floor and take him to the Dialysis Clinic. Driver #1 then proceeded to call 911 for assistance. Driver #1 asked Resident #45 if he was ok and Resident stated that he was. Resident #45 stated to 911 personnel that he was not hurt, and they moved him back to the wheelchair. After Resident #45 was transferred to his chair by EMS (Emergency Medical Services) staff, Resident #45 stated that he had to go to the restroom Resident #45 required assistance prior to being dialyzed, Driver #1 transported Resident #45 back to the facility to receive care and Driver #1 then transported Resident #45 back to the Dialysis Clinic to be dialyzed without further incident. Driver #1 returned Resident #45 to the facility after dialysis was completed. There was no documentation that the nurse assigned to Resident #45 completed an assessment after incident on 2/9/24. Resident #45 was assessed by physician on 2/10/24 not related to this incident and no injuries were noted. The Passenger Services Manager provided documentation to validate that Driver #1 received education on the following policies and procedures on 2/13/24 and on 3/2/24: Expectations of Passenger Services Drivers', Mobile Cellular Device, Proper Transport Loading and Unloading Wheelchair Patients, General Safety, Motor Vehicle Accidents& Emergency Reporting Procedures to the facility administrator. On 10/14/24, the Passenger Services Manager notified the facility administrator that on 2/12/24 and 2/13/24, the Lead Driver accompanied Driver #1 on transportation routes and provided one-to one re-training as assigned by the Passenger Services Manager. Driver #1 reported back to work on 2/12/24. The Passenger Services Manager provided documentation to validate that Driver #1 received related education on the following policies and procedures: General Safety, Motor Vehicle Accidents & Emergency Reporting Procedures, Expectations of Passenger Services Drivers, Proper Transport Loading and Unloading Wheelchair Patients and Mobile Cellular Device to the facility administrator. Documentation of training and acknowledgment was signed on 2/13/24. On 3/2/24 Driver #1 was re-educated again on the following Policies and procedures: General Safety, Motor Vehicle Accidents & Emergency Reporting Procedures, Expectations of Passenger Services Drivers, Proper Transport Loading and Unloading Wheelchair Patients and Mobile Cellular Device and documentation of training was provided to the facility administrator. Documentation of training and acknowledgment was signed on 3/2/24. All residents who use wheelchair transportation services for medical appointment[s] are at risk of experiencing an adverse outcome as a result of this deficient practice. Current residents who had been transported by the transportation service within the last 30 days were interviewed on 10/12/24 and 10/13/24 by members from the IDT team, specifically the Resident Liaison, Rehab Manager, Activity Director and LPN/Unit Coordinator regarding any incidents or accidents where the resident was not immediately assessed for injuries occurred in transport. For current residents who were not able to be interviewed, the assigned transportation companions were interviewed 10/12/24 and 10/13/24 and no evidence of any additional deficient practice during transport was reported where drivers moved residents after an incident without being first assessed by 911 personnel or licensed nurse/physician. The Passenger Services Manager was interviewed by the facility Administrator on 10/11/24 and 10/13/24 related to any events of deficient practice reported from all drivers within the last 30 days which required immediate assessment for injuries. The Passenger Services Manager reviewed incident reports and communicated directly with all drivers providing services to the facility and found no evidence of any deficient practice during transport review period reported. The Passenger Services Manager also asked all drivers, including Driver # 1, if there were any accidents/incidents that occurred on transport that were not reported in the last 30 days and the drivers' responses indicated that there had not been any accidents/incidents that had not been reported during review period. On 10/13/24, the Passenger Services Manager confirmed with the facility administrator that interviews; and a review of transportation records for that past 30 days found no evidence of deficient practice with drivers providing service to residents at the facility. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The facility will take immediate action by informing Hospital system transportation services to remove Driver #1 from transporting facility residents to any off-campus appointments, Effective at 8:40 pm on 10/11/24. On 10/12/24, the Passenger Services Manager and the Facility Administrator reviewed the policy, Motor Vehicle Accident & Emergency Reporting Procedure and found the policy did not address skilled nursing facility residents and the policy section regarding emergencies was revised on 10/14/24 to reflect that for skilled nursing home residents, drivers are not to move patient until assessed by EMS or licensed nurse/physician, as listed below: Medical/Vehicle Emergencies: • If patient starts to slide or shift while in wheelchair during transport - Driver must pull over when safe to do so and seek help. i.e. Call 911 - fire dept. Each driver has a cell phone provided and other communication devices which are owned and managed through Mobile Medical Services not the facility. • Pull vehicle onto the shoulder of the road • Evacuate Patients and or passengers from the vehicle quickly and safely if vehicle is on fire • Administer first aid and use fire extinguishers as appropriate • Do not move patient. Patient must be accessed by Emergency Medical Services (EMS) or licensed nurse/physician • Drivers will immediately notify the Passenger Services Manager in the event of an incident/accident during transport • Call Atrium Health Security or contact 9-1-1 as needed for emergency help and update Mobile Medicine Passenger Services Dispatch at (704)512-7920 • If patient or passenger is injured, report this to your supervisor immediately so an online incident report can be done via CARE Event (A Care Event is an incident/accident report that involves resident safety) • Driver must remain with patients and/or passengers until all are transported to an emergency care facility if necessary • Have Atrium Health Security notify supervisor and department head as needed On 10/14/24 the facility administrator notified the Passenger Services Manager to immediately notify the facility administrator or charge nurse in the event of an incident/accident during transport. All current van drivers will receive education by 10/14/24. Any current van drivers who do not receive education by 10/14/24 (due to FMLA, leave, etc.) will be required to complete education prior to working a scheduled shift. All van drivers hired after 10/14/24 will be required to complete this training and education upon hire. The education will be required during annual orientation. Beginning 10/12/24, the Passenger Services Manager will immediately notify and provide all transportation services incident reports involving nursing home facility residents to the Administrator and Director of Nursing to ensure that timely resident assessments post medical/vehicle emergencies are completed. The alleged date of immediate jeopardy removal was October 15, 2024. On 10/16/2024 the facility's immediate jeopardy removal was validated by the following: The facility provided documentation to support immediate jeopardy removal including education provided by the Passenger Services Manager to the current drivers. Drivers were interviewed and they reported the procedure to follow if a resident falls on the van, including pulling the van over as soon as possible, calling 911 to request an assessment of the resident by an EMT, contacting the dispatcher to report the accident or incident. Drivers verbalized they were not to move the resident until an EMT, nurse, or physician had assessed the resident for injuries. The immediate jeopardy was removed on 10/15/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #62 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #62 was cognitively intact. He was not receiving an anticoagulant. He did not have any impairment to his upper and lower extremities. Review of Passenger Services Liftgate Use and Patient Safety Check (no date) supplied by the Passenger Services Manager revealed the following: I. Vehicle Liftgate Use & Safety Checks- - Always ride liftgate up when getting ready to offload patient - Ensure liftgate is in the upward position prior to attempting to unload patient - Do not ride liftgate up or down with the patient on lift II.Passenger Safety (Unload) - - Always ride the liftgate up when getting ready to offload patient - Ensure liftgate is in the upward (level with the floor in the rear of the van) position prior to attempting to unload patient and that the liftgate is level with floor of vehicle - Get in front of patient and push wheelchair onto liftgate and secure wheelchair by locking wheelchair brakes Review of Passenger Services Safety Briefing (no date) supplied by the Passenger Services Manager revealed the following: - To ensure the lift gate is in the upward position prior to attempting to offload a patient, always ride the lift gate up after entering from the rear of the vehicle. Review of the video and audio recording (which was center- rear facing) from the hospital owned transportation van dated 8/12/24 revealed the following: - At 6:08 PM the hospital owned transportation van, driven by Driver #1, returned to the facility with Resident #62's responsible party, Resident #62, and another resident. Resident #62 was observed in his wheelchair with his shoulder securement strap resting across his left upper arm. - At 6:09 PM to 6:10 PM, Driver #1 disconnected Resident #62's shoulder securement strap and Resident #62 remained in his wheelchair while another resident was being unloaded by Driver #1 via the lift gate. - At 6:12 PM Driver#1 returned to the hospital owned transportation van and entered from the rear. The lift gate was observed to be on ground level. Driver #1 unsecured Resident #62's wheelchair securement straps from behind. - At 6:13 PM Driver #1, who was behind Resident #62, was observed pulling Resident #62 backwards towards the rear of the hospital owned transportation van. As Driver #1 crossed the threshold at the rear of the hospital owned transportation van, an audible alarm sounded, and indicator lights lit up red and flashed, which indicated the liftgate was not in the upward position and there was a risk of falling out of the rear of the van. Driver #1 proceeded to fall out of the back of the hospital owned transportation van. She let go of Resident #62's wheelchair as she was falling backwards out of the hospital owned transportation van. Resident #62 was seated in his wheelchair and remained in motion rolling backwards out of the hospital owned transportation van. Driver #1's arm was observed to come up to meet the back of Resident #62's wheelchair as Resident #62 and his wheelchair proceeded to roll off the back of the hospital owned transportation van. Resident #62 continued rolling backwards in his wheelchair and his legs were seen coming up in the air as his chair exited the rear of the hospital owned transportation van and pivoted to where the resident was still seated but facing upwards. Resident #62 then was observed to be slightly unseated from his wheelchair. The wheelchair wheels were observed to be hanging off the back of the hospital owned transportation van. Driver #1 ceased to be in the field of vision. Driver #1 and Resident #62 could be heard yelling/calling out for help. Resident #62's wheelchair wheels were suspended in air and still spinning. - At 6:14 PM to 6:16 PM facility staff were observed exiting the facility and saw Driver #1 lying on her back on the lift gate on the ground and Resident #62 in his wheelchair tilted to the left resting on Driver #1 and ran back inside to get help. More staff responded and came out to assist. The Unit Manager also responded. Staff were observed standing over Driver #1 and Resident #62. The Unit Manager was observed entering the hospital owned transportation van from the side entrance and walking to the rear of the hospital owned transportation van towards the lift gate. The Unit Manager was observed bending over and grabbing the wheelchair legs while other staff were observed assisting Driver #1 from underneath Resident #62 and his wheelchair. Resident #62's wheelchair was then placed to the left side of the hospital owned transportation van. Driver #1 was observed to stand and stretch. Staff continued to stand as Resident #62 was being assessed. Resident #62 was assisted by staff back to his wheelchair and taken back inside the facility by staff. An observation was completed on 10/11/24 at 4:55 PM of the Administrator obtaining the measurement of the back of the transportation van where Resident #62 fell backwards in his wheelchair to where he and his wheelchair landed measured three (3) feet and ten (10) inches. Review of the Care Event (incident report) notification completed by the Passenger Services Manager dated 8/12/24 revealed the following information: Event Description- Driver was unloading patient from wheelchair van. Patient fell out of the wheelchair as driver was exiting patient from vehicle. Driver statement will be sent. Date Occurred: 8/12/24. Incident Location (facility): Hospital System- Health Mobile Medicine. Extent of Harm: Mild Harm. Event Type: Fall. Review of Driver #1 witness statement dated 8/12/24 read in part: Driver #1 was unloading two patients. Driver #1 unloaded the first patient and took them inside the building. Driver #1 returned to the hospital owned transportation van on the passenger side, where the door was already opened, and unlocked the seatbelt and the wheelchair securement straps. Driver #1 was behind the wheelchair to pull it back to the rear of the hospital owned transportation van not realizing the lift gate was down on the ground and not in the level position. The safety beeper went off. At that point, Driver #1 was too far back and fell backwards, still holding on to the wheelchair. Driver #1 let go of the wheelchair, so it stayed on the hospital owned transportation van but was tilted back. Driver #1 balanced and held the wheelchair up with her feet as long as she could and called out for help. When Driver #1 strength gave out, the patient and wheelchair fell back onto Driver #1 body breaking the fall. Driver #1 braced his [the resident] upper body with her left arm and hand until help arrived. An interview with Driver #1 on 10/10/24 at 4:33 PM revealed that she and Resident #62 fell out of the back of the hospital owned transportation van on 8/12/24. Driver #1 explained she went to unload Resident #62 from the hospital owned transportation van after unloading another resident. Driver #1 stated she entered the hospital owned transportation van from the rear and proceeded to unsecure Resident #62 from the wheelchair securement straps from behind. Driver #1 explained she remained behind the wheelchair of Resident #62 and wheeled him backwards towards the lift gate area. Driver #1 voiced she did not realize the lift gate was down. Driver #1 continued to explain while moving Resident #62 towards the lift gate area, walking backwards as she was pulling Resident #62 in his wheelchair backwards, Driver #1 verbalized the alarm/sensor sounded as she crossed the threshold at rear of the van. Driver #1 stated the alarm sound startled her. Driver #1 proceeded to explain she fell backwards out of the hospital owned transportation van taking the wheelchair with Resident #62 with her as she fell. Driver #1 further stated she held the wheelchair with Resident #62 in the air with her feet and hands as long as she could (no timeframe given) and hollered for help. Driver #1 expressed she started to fatigue and the wheelchair with the resident fell on top of her as she laid on the lift gate which was at ground level. Driver #1 voiced Resident #62 did not hit the ground, because she had absorbed his fall. A telephone attempt was made on 10/11/24 at 11:05 AM to speak with the responsible party for Resident #62 without success. Review of the post fall evaluation completed by the Unit Manager dated 8/12/24 revealed the following: Fall Occurrence: August 12, 2024. Day of Week of Fall Occurrence: Monday. Location of Fall Occurrence: Exterior. Description of Fall Activity: Other. Assistive Device: Lift and Walker. Post Fall Injury: No apparent injury. Post Fall Notification (date/ time/ name): August 12, 2024/ 7:25 PM/ Nurse Practitioner. Outcome of Notification: No new order received. Date/ Time of Family Notification/ Family Contact: August 12, 2024/ 7:25 PM/ onsite discussion with responsible party. Post Fall Analysis (current interventions in place): wheelchair for locomotion, wheelchair locked when not in use, non-skid footwear. Review of the Unit Manager nursing progress note dated 8/12/24 read in part: Resident #62 observed laying on back on top of Driver #1 on the lift of the hospital owned transportation van with wheelchair laying on top of Resident #62. The lift gate was resting flat on the ground. Driver #1 stated she broke his fall. Staff came in from the back of the hospital owned transportation van and pulled the wheelchair off of the resident and were able to position resident to where the driver could slide out from under him. Staff assessed Resident #62 for injury with no apparent injuries noted. Staff assisted Resident #62 to his wheelchair and assessed head for injury, none noted. Nurse Practitioner (NP) was made aware and going to complete full assessment of resident for injury. Responsible party made aware and appreciative of care. An interview with the Unit Manager was completed on 10/11/24 at 11:34 AM. The Unit Manager stated she was in her office working and a family member or visitor was leaving out of the facility. The Unit Manager proceeded to state the family member or visitor started hollering her name. The Unit Manager responded and ran towards the front entry hallway per the request. The Unit Manager explained when she arrived at the front entrance door, the lift was down on the back entry of the hospital owned transportation van and Driver #1 was lying flat on her back with her feet against the back of the hospital owned transportation van (bumper area), Resident #62 was on top of Driver #1 on his back, the wheelchair was half on top of him/ half under him somehow. The Unit Manager recalled she immediately went to remove the wheelchair from on top of resident. She stated she could not remove the wheelchair from on top of Resident #62, so she went in the hospital owned transportation van through the side entrance to remove the wheelchair from the top angle. The Unit Manager voiced she was able to remove the wheelchair and get it upright inside the hospital owned transportation van. The Unit Manager stated she exited the hospital owned transportation van with the wheelchair through the side entrance. The Unit Manager further stated that she and another nurse quickly assessed Resident #62 for immediate injury so they could get Driver #1 from underneath him and get Resident #62 lying flat. The Unit Manager and another nurse assisted Driver #1 from underneath Resident #62. The Unit Manager assessed Resident #62 which included movement of all extremities, skin assessment (abrasions, bruising or red marks), and assessing for pain. The Unit Manager recalled Resident #62, and Driver #1 were able to verbalize that Resident #62 did not hit his head during the incident. The Unit Manager and other staff were able to provide support to Resident #62 and assist him with standing so he could transfer to his wheelchair. The Unit Manager had a staff person assist Resident #62 back into the facility. The Unit Manager voiced the NP was onsite and assessed Resident #62 after the incident. The Unit Manager did not recall Resident #62 sustaining any injuries. Resident #62's responsible party was onsite during the incident, but the Unit Manager could not recall if Resident #62's responsible party witnessed the incident. A telephone interview was completed with the Passenger Services Manager on 10/11/24 at 1:56 PM. The Passenger Services Manager recalled the incident involving Resident #62. The Passenger Services Manager stated she was contacted by Driver #1 at some point after the incident. The Passenger Services Manger did not recall the exact time she was notified of the incident. Driver #1 expressed that she forgot to place the lift gate in the upward position while unloading a resident. The Passenger Services Manager stated the video footage in the hospital owned transportation vans had both audio and visual components. The Passenger Services Manager communicated when she reviewed the video footage, the lift gate was not in the upward position and Driver #1 and Resident #62 fell out the back of the hospital owned transportation van onto the lift gate. The Passenger Services Manager recalled seeing the red light flash but did not recall hearing the alarm sound when she reviewed the video footage. The Passenger Services Manager stated Driver #1 was provided re-education on what steps should have been followed when unloading a patient, inclusive of lift gate use, via telephone call on 8/12/24 due to the Passenger Service Manager being out of the office. An in-person coaching, counseling and re-education session on the process for unloading a patient, inclusive of lift gate use, was completed by the Passenger Service Manager on 8/15/24. A telephone attempt was made on 10/11/24 at 11:15 AM to speak with the previous Director of Nursing without success. An interview completed on 10/14/24 at 11:59 AM with Nurse #3 revealed a family member returned inside the building and hollered that help was needed outside. Nurse #3, who was sitting at the nurses' station, and other staff responded. Driver #1 was lying on the lift which was all the way to the ground, Resident #62 was on top driver, and Resident #62's wheelchair was tilted backwards and hung up in the mechanical parts of the lift. Nurse #3 communicated Resident #62 was truly resting on top of driver. Nurse #3 assisted with Resident #62 returning him inside of facility and to his room. The nurse recalled the Unit Manager completed a post fall assessment and informed the NP. Nurse #3 recalled Resident #62 did not have any visible marks or abrasions. Resident #62 did not verbalize any complaint or pain. Nurse #3 stated that Resident #62 was in a pleasant mood after the incident and requested staff to change his clothes due to wearing paper scrubs from his appointment. Review of the Nurse Practitioner assessment dated [DATE] read in part: Patient seen today due to recent fall. Patient had an incident of a fall when he was being transported. Patient moving all extremities at baseline. No visible signs of injury. Denies any complaints. Notes that he is hungry and ready for dinner. Assessment and Plan: Ambulatory dysfunction- physical therapy and occupational therapy. Fall precautions- last fall noted on 8/12 when wheelchair tipped backwards on transport van, but patient sustained no injuries. An interview with the Nurse Practitioner (NP) was completed on 10/14/24 at 10:50 AM. The NP stated she was aware of the incident involving Resident #62's fall out of the hospital owned transportation van. The NP explained she was onsite on 8/12/24 but was not certain if the incident occurred prior to her arrival or when she came out of her office. The NP recalled Resident #62 was back in his room sitting in his wheelchair when she visited him. The NP verbalized she spoke with Resident #62 to determine if he was at his baseline and had any complaint of pain or injury. The NP stated Resident #62 was alert, she was able to determine there was no notable change in orientation (at baseline resident had some confusion), and Resident #62 was able to describe the incident. Resident #62 was able to move all extremities while sitting in his wheelchair. The NP stated she did not have the resident stand. However, he was able to lift legs and push legs against her without any problems. Same with his arms. He had no abrasions on his upper or lower extremities, and no open areas/ abrasions noted to his head area. The NP recalled Resident #62 had no complaints of pain or discomfort. An interview with the Director of Nursing Services was completed on 10/14/24 at 3:05 PM. The Director of Nursing Services stated she was notified of the event a few days later (uncertain of actual date). She explained she was made aware of transport moving someone out the back of the hospital owned transportation van and both resident and driver fell out the back of the hospital owned transportation van due to the lift gate not being in the appropriate placement. The Director of Nursing Services received email notifications after the event of in-servicing/ re-education and training being provided to Driver #1. The Passenger Services Manager completed the plan of correction following the fall from the hospital owned transportation van involving Driver #1 and Resident #62. The Director of Nursing Services was uncertain of the collaboration with facility administrative staff regarding the incident. The Director of Nursing Services explained the process after an incident should include assessment of the resident by a licensed professional, a root cause analysis, and have a plan of correction in place to prevent any further incidents, collaboration between transportation staff and facility administrative staff (if the incident involved a hospital owned transportation van). The Director of Nursing Services was not aware if the facility investigated the root cause and implemented interventions to prevent the incident from happening again. An interview was completed with the unlicensed Administrator on 10/14/24 at 3:51 PM. The unlicensed Administrator communicated Driver #1 did not adhere to the safety mechanism on the lift gate. The alarm sounded and the light flashed. The Administrator continued to communicate Driver #1 did not place the lift gate in the right position when unloading Resident #62 and this caused the incident to occur. The unlicensed Administrator was notified of immediate jeopardy on 10/11/24 at 7:17 PM. The facility provided the following credible allegation of immediate jeopardy removal plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: 1. On 2/09/24 Resident #45 was at the dialysis clinic when the Administrator was notified by a staff member that Resident #45 experienced a fall while in van transport. Driver #1 did not notify the facility administrator nor her supervisor, the Passenger Services Manager, about the accident. On 2/09/24 the Administrator contacted the Passenger Services Manager to begin an investigation and require education of Driver #1. On 2/09/24 Driver #1 was transporting Resident #45 to a dialysis appointment in the Hospital system transportation van. Driver #1 put on the brakes suddenly and Resident #45 slid from his wheelchair onto the floor. The Passenger Services Manager conducted the investigation and completed the review of the video revealed that the lap belt and shoulder harness had excessive slack and did not appear to be snug to the resident as per manufacturer's instructions. Driver #1 went to Resident #45 and attempted to pick up Resident #45 and placed him back in his wheelchair but was unsuccessful and he slid back to the floor where he was in a seated position. Driver #1 returned to the driver's seat, and then drove the van to the Dialysis Clinic, with Resident #45 on the floor of the van. The Dialysis Clinic is approximately 1.2 miles from the facility. On 2/10/24, Fleet Services inspected the van post incident and found no malfunctions of the securement system. On 10/13/24, the facility administrator interviewed the Passenger Services Manager, and she stated that all drivers complete a daily pre-trip audit checklist which includes checking securement straps (lap belt and shoulder harness) for signs of fraying, malfunctioning buckles and wheelchair tie downs before the drivers' first trip of the day. Driver #1 did not report any pre-trip malfunctioning of the van securement system to the Passenger Services Manager on 2/9/24. The Passenger Services Manager provided documentation to validate that Driver #1 received related education on the following policies and procedures: General Safety, Motor Vehicle Accidents & Emergency Reporting Procedures, Expectations of Passenger Services Drivers, Proper Transport Loading and Unloading Wheelchair Patients and Mobile Cellular Device to the facility administrator. Documentation of training and acknowledgment was signed on 2/13/24. On 3/2/24 Driver #1 was re-educated again on the following Policies and procedures: General Safety, Motor Vehicle Accidents & Emergency Reporting Procedures, Expectations of Passenger Services Drivers, Proper Transport Loading and Unloading Wheelchair Patients and Mobile Cellular Device and documentation of training was provided to the facility administrator. Documentation of training and acknowledgment was signed on 3/2/24. On 10/14/24, the Passenger Services Manager notified the facility administrator that on 2/12/24 and 2/13/24, the Lead Driver accompanied Driver #1 on transportation routes and provided one-to one re-training with return demonstration as assigned by the Passenger Services Manager which included manufacturer's instructions for securing the lap belt, shoulder harness and cease driving when resident is not securely seated or when resident has fallen out of wheelchair. Driver #1 reported back to work on 2/12/24. Documentation of training and acknowledgment was signed on 2/13/24 by Driver #1. 2. On 8/12/24 Driver #1 returned to the facility from medical appointments with two residents. Driver #1 offloaded one resident and returned the resident back into the facility. Resident #62 was still on the van waiting to be offloaded by Driver #1. Driver #1 unlocked the seat belt and unbuckled the hooks from the wheelchair. When Driver #1 began to pull resident off the van onto the liftgate the safety alarm alerted, indicating an unsafe lift position. Driver #1 stated that she was not in position to stop while in motion and Driver #1 fell off the van onto the grounded lift gate. Driver #1 did not realize that she did not have the liftgate in the correct position which caused the incident to occur. Resident #62, while remaining in wheelchair, fell onto Driver #1. Resident #62 was immediately assessed by a licensed nurse and no apparent injuries were noted. On 8/13/24, the Physician assessed resident for injury related to the incident and no injuries were noted. Passenger Services Manager provided the following employee action and education for Driver #1 on 8/12/24. Driver #1 continued to transport SNF residents without interruption after 8/12/24 incident. Education and actions were validated by the facility administrator on 9/11/24: 8/12/24: Driver #1 reeducated by Passenger Services Manager on the wheelchair van lift gate which included offloading resident from van Driver #1 acknowledged education of Lift gate Use and Patient Safety. Per manufacturer's instructions 8/13/24: Vehicle taken out of service to have liftgate evaluated. Fleet Service found the liftgate was functioning with no concerns and van was put back in use. 8/16/24: Spot Check/Observation/Retraining conducted by Lead Driver II (the senior driver and provides education and training for drivers). Pre-trip inspections are to be conducted daily by Driver assigned prior to driving patients in van. Lead Driver II will randomly audit all drivers pre-trip inspections. 8/19/24: Competency skills checklist document completed for Driver #1 by Lead Driver II. Competency skills checklist includes but not limited to the following for all Mobile Medical Services Drivers: Use of Two Way Radio Knows how to perform pre trip inspection checklist and able to note any vehicle issues Knows how to report vehicle accident within app Liftgate Use Checked Liftgate lights Check lift up and down button Run safety check on liftgate before using for passengers Demonstrated Use of Manual pump for liftgate Vehicle/Liftgate Operations Demonstrates and discuss concepts of safety always Evaluates loading and unloading zones for hazards Opens and properly secures van doors Assures level landing area and clear path of operation for lift Assures liftgate is in the up position prior to offloading wheelchair patient Driver completes a visual inspection of resident/patient wheelchair (excessive items in chair, leg lifts, functioning brakes, rolls freely) Driver identifies weight limit of the lift Put wheelchair patient on the lift in the forward position or per the lift manufacturers recommendation Secured wheelchair on lift. Pushed wheelchair onto van and locked wheelchair brakes Correctly operated lift Driver returns lift control to appropriate location Wheelchair Securement and Patient Restraint Communicated with patient what you are doing (reaching across them to place shoulder harness and lap belt on) Secured back straps Confirms floor anchor position for straps is within the width of the wheelchair frame Pulls straps straight out to chair and attaches to appropriate anchor point on the wheelchair frame Does not allow strap to twist Allows straps to retract and manually tightens them by twisting the ratchet knob Placed lap strap around the patient and locked it in place Secured front straps Identifies lap or lap/shoulder belt system Assures restraint belt is against patient and does not have slack Assures shoulder strap does not twist Positions lab belt low on torso at area of pelvic arch (hips) Positions buckle on the right side Positions shoulder belt over shoulder and not against neck Positions shoulder strap at level with or higher than shoulder Ensures that straps not compromised with blankets that are over patients Watchful of any items that could prevent a safe patient securement Incident & Medical Reporting Correctly stated how an Incident is Reported Involving a Patient Understands process of notification and documentation of any incident All residents who use wheelchair transportation services for medical appointments are at risk of experiencing an adverse outcome as a result of this deficient practice. Residents who experienced transport by the transportation service within 30 days were interviewed on 10/12/24 and 10/13/24 by the following members from the Interdisciplinary team (IDT) for review and discussion: Activities Director, Rehab Manager, Licensed Practical Nurse/Unit Coordinator and Resident Liaison. Interviews were related to any incidents or accidents while in transport occurred. No evidence of any additional deficient practice during transport was reported. For current residents who were not able to be interviewed, the assigned transportation companions were interviewed 10/12/24 and 10/13/24 and no evidence of any additional deficient practice during transport was reported. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The facility will take immediate action by informing hospital system transportation services to remove Driver #1 from transporting facility residents to any external appointments, Effective at 8:40 pm on 10/11/24. Beginning 10/12/24, the Passenger Services Manager will conduct in person training with all transportation drivers assigned to the facility, including return demonstration of offloading and securement of passengers. The training will include the Safety Briefing slide (providing a visual of the correct position for the liftgate); the Passenger Services Liftgate Use; Patient Safety Check requirements. Training and Education will also include offloading residents from the van and proper securement with the wheelchair van wheelchair and resident securement system according to the manufacturer's instructions. Competency skills checklist was completed for all drivers and continues annually upon orientation. Any transportation drivers who do not receive the education by 10/12/24 (due to FMLA, leave, etc.) will be required to complete education prior to working a scheduled shift. All newly hired drivers assigned to the facility will be required to complete this training and education upon hire and all drivers will be required to complete this education annually. Beginning 10/12/24, the Passenger Services Manager will provide documented evidence of training and education of all assigned drivers to the Administrator and Director of Nursing. Alleged Date of Immediate Jeopardy Removal: 10/15/24 The facility's immediate jeopardy removal plan was validated on 10/16/24 by the following: The facility provided documentation to support their corrective action plan including education provided by the Passenger Services Manager to the current drivers who operate the hospital owned transportation vans. The documentation was reviewed for each driver and each driver was found to have received the education and it was documented each driver provided return demonstration to the Passenger Services Manager. Driver #2 demonstrated the correct method to secure a wheelchair with a resident into the hospital owned transportation van using the securement system. Driver #2 demonstrated the correct procedure to remove a resident from the hospital owned transportation van including riding the hospital owned transportation van lift gate to the back of the hospital owned transportation van and entering the hospital owned transportation van from the rear. Interviews were conducted with a sample of drivers, and they were able to report the pre-trip safety checklist, securing a wheelchair passenger into the hospital owned transportation van, and safe removal of a wheelchair passenger from the hospital owned transportation van. The facility's date of Immediate Jeopardy removal of 10/15/24 was validated. Based on observations, record review, review of audio/video footage, and Nurse Practitioner (NP), Passenger Services Manager, resident and staff interviews, the facility failed to provide safe transportation for Resident #45 in the hospital system transportation van to the dialysis center. On 2/9/24 while en route Driver #1 stopped abruptly, and Resident #45 slid out of his wheelchair to the floor of the van. Driver #1 was unable to assist Resident #45 back into his wheelchair and proceeded to drive to the dialysis center with Resident #45 sitting on the floor of the van. In addition, on 8/12/24, Driver #1 failed to ensure the lift gate was in the elevated position before unloading Resident #62 from the back from the van. Driver #1 stood behind Resident #62's wheelchair and wheeled Resident #62 towards the back of the van and lift gate. Driver #1 fell out of the back of the transportation van and Resident #62 and his wheelchair rolled out of the back of the transportation van and landed on top of Driver #1. There was a high likelihood of a serious adverse outcome or injury when the manufacturer's instructions for securing and unloading residents from the transportation van are not followed. This was for 2 of 5 residents reviewed for accidents (Resident #45 and Resident #62). Immediate jeopardy began on 2/9/24 when Resident #45 fell to the floor of the transportation van while being transported to his dialysis appointment. Immediate jeopardy began on 8/12/24 for Resident #62 when Driver #1 wheeled the resident out of the back of the