**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, staff, physician and contract transport company interviews, the facility's contracted transport driver (Driver #1) failed to leave Resident #12 in place for a clinical assessment of injury after a fall that occurred during transport. Resident #12 was being transported back from a medical appointment in a contract transport van while unsecured in her wheelchair. Driver #1 made a sudden stop which caused Resident #12 to fall forward out of her wheelchair onto the van floor. Driver #1 pulled the van off to the side of the road and transferred Resident #12 off the van floor back into her wheelchair and continued back to the facility. Driver #1 was not qualified to provide a comprehensive physical assessment to determine if the resident sustained any injuries. Upon arrival at the facility, Driver #1 did not notify facility staff of the resident's fall. Resident #12 notified staff of the fall in the van and was assessed by nursing staff and noted to have swelling and a skin tear to her left knee. A hospital computed tomography (CT) scan revealed Resident #12 had suffered a distal (away from the center of the body) left fracture to the femur (break in bone above left knee joint) due to her fall in the van. This deficient practice occurred for 1 of 3 sampled residents reviewed for quality of care (Resident #12). The findings included: Resident #12 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis (MS), muscle weakness, contractures of the left knee, hip, wrist, and of the right knee and hip. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact, utilized a wheelchair for mobility, and dependent for assist with transfers. Resident #12 was also coded as having on-going pain and receiving scheduled pain medications. Review of a physician order dated 10/01/23 revealed Resident #12 received Gabapentin (used for pain) 300 milligrams (mg) 1 tablet by mouth every 8 hours as needed (prn) for pain. Review of a physician order dated 10/01/23 revealed Resident #12 received Acetaminophen (mild to moderate pain) 650 mg 1 tablet by mouth every 4 hours as needed for mild pain. Review of Resident #12's Medication Administration Record (MAR) from 10/1/23 through 10/5/23 revealed the following administrations of Resident #12's prn pain medications Gabapentin 300 mg and Acetaminophen 650 mg: - 10/1/23: Gabapentin at 10:44 AM (pain level 1) (on a scale of 1 to 10 with 10 being the worst pain possible) - 10/2/23: Acetaminophen at 8:08 AM (pain level 0), Acetaminophen at 3:27 PM (pain level 0) - 10/3/23: Gabapentin at 8:05 AM (pain level 7), Acetaminophen at 9:06 AM (pain level 7), Acetaminophen at 3:23 PM (pain level 8) - 10/4/23: Acetaminophen at 7:55 AM (pain level 1), Acetaminophen at 7:58 PM (pain level 0) - 10/5/23: Acetaminophen at 5:19 AM (pain level 0), Gabapentin at 3:01 PM (pain level 2) Review of facility van incident report dated 10/05/23 written by Unit Manager #1 read in part: [Resident #12] fell from chair after [Driver #1] pressed the brakes while out of facility being transported by outside services. [Resident #12] stated, he slammed on the brakes, and I fell on the floor, he picked me up and put me back in chair. Assessment completed, transport company owner notified, physician notified, vital signs taken, skin assessment completed. Review of Driver #1's statement dated 10/5/23 indicated, [Driver #1] was driving on my way through greenlight, suddenly had to brake, [Resident #12] went forward and hit her knee against driver seat chair. A phone interview was attempted with Driver #1, but he was unable to be reached. An interview was conducted with Resident #12 on 08/20/24 at 11:00 AM revealed on 10/05/23 she had been transported to an appointment by the transport company and on her way back to the facility, Driver #1 had secured her wheelchair in the van but forgot to secure her into her wheelchair, so when he had to make a sudden stop she fell out of her wheelchair onto the van floor. She stated Driver #1 pulled the van off the side of the road and assisted her back into her wheelchair and transported her back to the facility. Resident #12 revealed as soon as she got back to the facility, she notified the Director of Nursing (DON) and the Administrator about the fall and they asked her what happened, assessed her for injuries and at the time her left knee was swollen some and had a skin tear, but she was not in any real pain. Resident #12 revealed she believed Driver #1 should have either called 911 for help after the fall prior to putting her back into her chair or taken her to the hospital to be assessed. Review of a physician order dated 10/05/23 revealed an order for a mobile x-ray to be completed on Resident #12's left ankle, left foot, left knee, left tibia (located on inside of leg, below knee joint, and forms top of ankle joint), and left fibula (located on outside of leg, below knee joint, and forms top of ankle joint). Review of an on-call physician note dated 10/06/23 indicated on 10/05/23, Resident #12 had a fall from her wheelchair on transportation van. Resident #12's left knee was swollen, she complained of increased pain at a level 10 in her left knee and leg, and her x-ray results had not been received. Ibuprofen 400 mg twice daily for 3 days and Tylenol 500 mg three times daily for 3 days was ordered for Resident #12's acute pain post fall. Review of on-call physician orders for Resident #12 dated 10/06/23 indicated Ibuprofen 400 mg twice daily for 3 days for acute pain post fall and Tylenol 500 mg three times daily for 3 days for acute pain post fall. Review of a mobile x-ray dated 10/06/23 of Resident #12's left knee revealed a moderately displaced (more complex fracture because bones are out of alignment or in pieces) distal left fracture of the femur of indeterminate age (not able to determine how long-ago fracture occurred). Clinical follow-up was recommended. Review of an on-call physician note dated 10/06/23 revealed Resident #12's x-ray results were reviewed with no new treatment orders. The on-call physician indicated to continue to monitor and follow-up with the resident's primary care physician was recommended. Review of Resident #12's Medication Administration Record (MAR) from 10/6/23 through 10/8/23 revealed the following administrations of Resident #12's pain medications Tylenol 500 mg and Ibuprofen 400 mg and prn pain medication Gabapentin 300 mg: - 10/6/23: Gabapentin at 12:14 AM (pain level 2), Tylenol at 2:00 PM (pain level of 10), Ibuprofen at 8:00 PM (pain level 0), Tylenol 10:00 PM (pain level of 0), and Gabapentin at 11:24 PM (pain level 1) - 10/07/23 Tylenol at 6:00 AM (pain level 0), Gabapentin at 7:35 AM (pain level 1), Ibuprofen at 8:00 AM (pain level 0), Tylenol at 2:00 PM (pain level 0), Gabapentin at 3:24 PM (pain level 1), Ibuprofen at 8:00 PM (pain level 0), and Tylenol at 10:00 PM (pain level of 2) - 10/08/23 Tylenol at 6:00 AM (pain level 0), Ibuprofen at 8:00 AM (pain level 0), Gabapentin at 10:47 AM (pain level 1), and Tylenol at 2:00 PM (pain level of 0) Review of an on-call physician note dated 10/08/23 revealed Resident #12 complained of pain in her stomach area when inhaling and requested to be sent out to the hospital. Resident #12 was sent out from the facility to the hospital at 4:05 PM. Review of the hospital Discharge summary dated [DATE] revealed Resident #12 was seen at emergency department (ED) for a fall and shortness of breath. Resident #12 had an abrasion and edema (swelling) to the left knee and a CT scan was obtained and revealed a distal femur fracture on the left and some possible bruising to the ribs as a result of the fall. The consulting ED provider did not recommend any emergency intervention given that Resident #12 was non-ambulatory, and wheelchair bound. Resident #12 was discharged back to the facility with an order for Naproxen (treat fever and pain) 375 mg by mouth twice daily and follow-up with orthopedics. During interview with Resident #12 on 8/20/24 at 11:00 AM she revealed on the day after the fall (10/06/23), her pain had gotten worse around her left knee and the facility administered her pain medications and completed an x-ray of her left side. She stated a couple of days later (10/08/23) she started having some trouble breathing and was sent out to the hospital where they confirmed she had broken her left leg and bruised her ribs because of the fall. Resident #12 revealed the hospital administered her some more pain medication, referred her to an orthopedist, and sent her back to the facility. An interview conducted with Director of Nursing (DON) on 8/21/24 at 12:06 PM revealed she was familiar with Resident #12. She stated on the afternoon of 10/05/23, Resident #12 had entered the facility by herself in her electric wheelchair after being transported to a medical appointment by their contract transport company. The resident stated that she had fallen on the van and Driver #1 picked her up and placed her back into her wheelchair after the fall and transported her back to the facility. She (the DON) revealed she immediately assessed Resident #12 for injury and noted a skin tear to her left knee with some swelling. The DON stated she notified the physician of Resident #12's fall on 10/05/23 and received an order for a mobile x-ray of the left knee. A mobile x-ray was completed on 10/06/23 and revealed a distal left leg fracture of the femur but was not able to determine the age of the fracture due to Resident #12's contractures and follow-up was recommended. She revealed the on-call physician was notified of the results and did not order any further treatment until reviewed by the facility physician. The DON stated on 10/08/23 Resident #12 was complaining of stomach pain when taking a deep breath and requested to be sent out to hospital. The on-call physician was notified, and orders were received for her to be sent out. She indicated a CT scan completed at the hospital on [DATE] revealed Resident #12 had suffered a left leg fracture of the femur and suspected bruised ribs from the fall in the van. Resident #12 returned to the facility with an order to follow-up with orthopedics outpatient. The DON also revealed after Resident #12 had fallen into the van floor, Driver #1 should have immediately contacted the facility and medical personnel to come and assess Resident #12 prior to moving her back into her wheelchair to keep from possibly causing further injury or trauma. A telephone interview conducted with the physician on 8/21/24 at 4:55 PM revealed he was familiar with Resident #12 and her fall on the van on 10/05/23. He stated he was notified on the day the accident had occurred and approved a mobile x-ray order for Resident #12's left side extremities due to her left knee showing signs of swelling. He revealed the mobile x-ray and the CT scan from the hospital both showed Resident #12 had suffered a left leg femur fracture due to the fall and recommended follow-up with outpatient orthopedic. The physician stated Resident #12 had MS which caused her to have contractures in all her extremities and suspected demineralization (loss of bone minerals faster than can be replaced) that made it easier for injury. He revealed he had been told by the DON that Driver #1 did not have her assessed by medical personnel prior to moving her after the fall. He indicated he would expect medical personnel to be notified immediately anytime a resident sustains a fall so an assessment of injury can be completed prior to them being moved. He stated moving a resident prior to them being assessed could cause further injury or trauma. An interview was conducted with the Administrator on 8/21/24 at 5:27 PM revealed she was familiar with Resident #12. She stated on 10/05/23, Resident #12 had been transported by their contract transport company to an appointment. She indicated when the resident arrived back at the facility, the resident reported that during her transport back to the facility she was not secured into her wheelchair and had fallen out of her wheelchair onto the van floor. Resident #12 stated Driver #1 had stopped the van and assisted her back into her chair and brought her back to the facility. The Administrator revealed while the DON was assessing Resident #12 for injury and contacting the physician, Driver #1 came into the facility and she attempted to interview him (Driver #1) about the incident, but he refused to give statement and left the facility. The Administrator indicated she contacted the Contract Transport Company Owner to notify them about the incident. She stated the owner of the transport company assisted her with receiving a written statement about the incident from Driver #1 and was able to view camera footage from the van to corroborate Resident #12's statement of how the fall occurred, that she had not been secured into her wheelchair, and Driver #1 did not contact medical personnel to assess her (Resident #12) after the fall prior to transporting her back to facility. The Administrator revealed Resident #12 had suffered a left leg femur fracture and bruised ribs from the fall. She stated according to the information received from the transport company, Driver #1 was no longer employed with the company and had received prior education on accident protocols which included notifying the facility and medical personnel when a resident had been involved in an accident prior to moving resident or proceeding forward with transport. A telephone interview conducted with the Contract Transport Company Owner on 8/22/24 at 9:29 AM indicated on 10/05/23, he was notified by the facility of the fall incident involving Driver #1 and Resident #12. He stated he received a written statement from Driver #1 and reviewed video footage from the van. Driver #1 failed to secure the lap belt and when he (Driver #1) had to stop suddenly Resident #12 fell out of her wheelchair onto the van floor. He revealed after the fall, Driver #1 pulled the van over, assisted Resident #12 back into her wheelchair and transported her back to the facility. He stated Driver #1 was no longer employed with the company and all drivers received training prior to transporting on van safety and the protocol on what to do if an accident occurred. The Contract Transport Company Owner stated Driver #1 should have pulled over, stopped the van, contacted 911 and the facility, and waited for Resident #12 to be assessed by medical personnel prior to her being moved to prevent any further injury to the resident. The facility was notified of immediate jeopardy on 8/22/24 at 5:50 PM. The facility provided the following corrective action plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; The identified resident (Resident #12) is still a current Resident at the facility. Resident #12 was picked up by a contract transportation driver from a scheduled neurology appointment for transport back to the facility. Prior to leaving the appointment, the contracted driver secured Resident #12 wheelchair, but failed to secure Resident #12 seatbelt leaving her unsecured. During transport, the contracted driver had to slam on brakes causing Resident #12 to fall forward from her wheelchair into the van floor. Contracted Driver pulled off road and assisted Resident #12 back into her wheelchair and then continued to transport Resident #12 back to the facility. Contracted Driver failed to contact 911 and/or facility prior to moving Resident #12 from van floor and prior to placing her back into wheelchair after fall. The following actions after this incident: On 10/5/23, the facility initiated immediate investigation on 10/5/23. On 10/5/23, Resident #12 medical director (MD) and responsible person (RP) made aware of incident. On 10/5/23, Order obtained for x-ray to the left ankle, left foot, left knee, left tibia and left fibula. On 10/6/23, Resident #12 complained of pain on a level of 10 on a level 0-10, MD notified, and new orders obtained for the following: Ibuprofen 400mg take 1 tablet by mouth twice daily x3 days for acute pain post fall and Tylenol 500mg take 1 tab by mouth three times daily x3 days for acute pain s/p fall. Pain medication effective with a pain scale of 0 noted. On 10/6/23, x-ray results were obtained and showed the following, Left tibia/fibula- No fracture or dislocation is identified, bony structures are osteoporotic. Left ankle-No acute fracture, dislocation or osseous lesion, bony structures are osteoporotic. Left Knee- moderately displaced fracture of the distal diaphysis of the femur of indeterminate age. No dislocation is identified. Left Foot-soft tissue swelling of the foot. Bony structures are osteoporotic. No acute fracture or dislocation is identified. There is moderate hallux valgus (bony bump that forms on joint at the base of big toe), mild degenerative change of the interphalangeal (hinge shaped joint in toe) joint, first metatarsophalangeal (joint that connects toes to foot bone) joint and midfoot is present. On 10/8/2023, Resident #12 complained of pain when she inhales in her stomach area especially the left upper quad. Resident and Daughter requested for Resident to be sent out to the Hospital for Evaluation and treatment. Vital signs at that time were as follows: BP 114/72, P 68, Resp. 18, Temp. 97.8. Resident transported via ambulance and MD was notified of the transport. On 10/8/23 hospital x-ray revealed an acute comminuted (break into three or more pieces) and mildly displaced distal femoral fracture with minimal angulation. Soft tissue swelling adjacent to the fracture. A left hip gamma nail (metal implant used to stabilize fractures) seen, no dislocation. No evidence of knee joint effusion (abnormal fluid accumulation within knee joint). On 10/9/23, Resident #12 returned back to the facility via stretcher accompanied by two emergency management technicians (EMT) attendants. Resident complained of pain and discomfort to the left femur upon assessment pain meds were administered and effective. New orders from emergency department (ED) for Naproxen 375mg PO BID. Ortho follow up appointment with Orthopedic surgery as soon as possible. On 10/9/23, Facility made Resident #12 an Ortho appointment on 10/10/23 at 2:15pm. RP and MD made aware of the appointment. On 10/10/23, Resident #12 was taken to Ortho via facility transport. Ortho plan on 10/10/23 state Resident is not a strong surgical candidate given knee contracture, would not recommend a long leg cast at that time. Instead recommended a knee immobilizer and limit range of motion of including weight-bearing. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; The Director of Nursing reviewed the accidents for the last three months and there were no other situations where licensed nurses did not assess the resident before the resident was moved. Review completed on 10/9/23. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; The van drivers were re-educated on 10/9/23 by the Administrator on the proper procedures if a resident was to have a fall/injury or abnormal event in the facility van, that 911 is to be called prior to moving the resident. The education was already a component of the Transportation Driver orientation given by Administrator/Designee. The Administrator notified the contract transportation company on 10/5/23 via phone, and stated that until proof of driver training to include wheelchair procedures and calling 911, then contracted transportation will not be utilized. Beginning 10/9/23, Any transportation from contract services was required to provide the driver's PASS (Passenger Assistance Safety and Sensitivity) training to the Administrator/Designee prior to transporting the facilities residents. These competencies are maintained by the Administrator/Designee. The contracted transportation supervisor who is PASS (Passenger Assistance Safety and Sensitivity) Certified completed education for contracted drivers on 10/12/23 and ongoing; prior to transporting facility residents. This education included both wheelchair patent procedures and to contact 911 immediately should any emergencies with patients occur during transport. 4. Address how the facility plans to monitor its performance to make sure that solutions are sustained. Beginning 10/9/23 Director of Nursing/Designee audited incident/accident logs to ensure no resident had a fall during transportation and 911 wasn't called. Director of Nursing/Designee reviewed incident/accident logs 5 days a week for 4 weeks, 3 days a week for 4 weeks and weekly for 4 weeks. On 10/9/23 Administrator made the decision to take audits to the monthly Quality Assurance meeting for tracking, trending, and recommendations from the IDT team. Alleged Date of Immediate Jeopardy Removal and corrective action plan completion: 10/13/23 The facility's corrective action plan was validated on 8/27/24 by the following: Interviews with facility transporters revealed they had received education on proper procedures if a resident was to have a fall, injury, or accident in the facility van, that 911 was to be called immediately, do not move resident until assessed by a medical professional, and call facility to notify of incident. The education was included as a component of the transportation orientation. Contract transport company re-education dated 10/12/23 verified staff were educated on passenger safety and sensitivity training, wheelchair procedures, and calling 911 immediately for any emergencies during transport. Review of the audit tool for the review of the incident/ accident logs was completed with no issues noted. Interviews were also conducted with alert and oriented residents who had been transported since October 2023 with no concerns, incidents, or accidents identified. Interview with the Administrator revealed she had educated facility transport drivers on proper procedures if a fall, injury, or accident occurred while transporting to include calling 911 immediately and not moving resident until assessed by medical personnel and notifying facility of the incident. The Administrator also verified the contract transport company had educated their drivers on the proper wheelchair procedures, calling 911 for any emergencies during transport, and safety and sensitivity training. The facility's immediate jeopardy removal date and the corrective action completion date was validated as 10/13/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with resident, staff, physician and the contract transport company's owner, the facility's contracted transport driver (Driver #1) failed to provide safe transportation when Resident #12's lap belt was not applied leaving her unsecured in her wheelchair. Resident #12 was being transported back from a medical appointment when Driver #1 made a sudden stop resulting in Resident #12 falling forward out of her wheelchair onto the van floor on her left knee and rolling onto her left side. Driver #1 pulled the van off to the side of the road and transferred Resident #12 off the van floor back into her wheelchair and continued back to the facility. Resident #12 had swelling and a skin tear to her left knee. A hospital CT (computed tomography) scan revealed Resident #12 had suffered a distal (away from the center of the body) left fracture to the femur (break in bone above left knee joint) due to her fall in the van. This deficient practice occurred for 1 of 3 sampled residents reviewed for accidents (Resident #12). The findings included: Review of the contract van vehicle anchorages for the 4-point wheelchair securement systems manual dated 2007 read in part: The illustrated manual provided directions for securing wheelchairs for transport in the transportation van. Tracks on the floor of the van (L-track) where the pin connectors of the retractors locked in place and straps connected to the wheelchair by a J-hook (a J-shaped metal hook affixed to the fabric straps that were attached to the connector pins). The manual illustrated the position of the pin connectors indicated two rear connectors were directly behind the wheelchair and the two front pin connectors were secured to the front and side of each side of the wheelchair. The instructions directed to follow the tie down angles in the illustration and attached the J-hooks on the wheelchair frame in the proper locations and apply resident seatbelt. Resident #12 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis (MS), muscle weakness, contractures of the left knee, hip, wrist, and of the right knee and hip. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact, utilized a wheelchair for mobility, and dependent for assist with transfers. Resident #12 was also coded as having on-going pain and receiving scheduled pain medications. Review of a physician order dated 10/01/23 revealed Resident #12 received Gabapentin 300 milligrams (mg) 1 tablet by mouth every 8 hours as needed (prn) for pain. Review of a physician order dated 10/01/23 revealed Resident #12 received Acetaminophen 650 mg 1 tablet by mouth every 4 hours as needed for mild pain. Review of Resident #12's Medication Administration Record (MAR) from 10/1/23 through 10/5/23 revealed the following administrations of Resident #12's prn pain medications Gabapentin 300 mg and Acetaminophen 650 mg: -10/1/23: Gabapentin at 10:44 AM (pain level 1) (on a scale of 1 to 10 with 10 being the worst pain possible) -10/2/23: Acetaminophen at 8:08 AM (pain level 0), Acetaminophen at 3:27 PM (pain level 0) -10/3/23: Gabapentin at 8:05 AM (pain level 7), Acetaminophen at 9:06 AM (pain level 7), Acetaminophen at 3:23 PM (pain level 8) -10/4/23: Acetaminophen at 7:55 AM (pain level 1), Acetaminophen at 7:58 PM (pain level 0) -10/5/23: Acetaminophen at 5:19 AM (pain level 0), Gabapentin at 3:01 PM (pain level 2) Review of facility van incident report dated 10/05/23 written by Unit Manager #1 read in part: [Resident #12] fell from chair after [Driver #1] pressed the brakes while out of facility being transported by outside services. [Resident #12] stated, he slammed on the brakes, and I fell on the floor, he picked me up and put me back in chair. Assessment completed, transport company owner notified, physician notified, vital signs taken, skin assessment completed. Review of Driver #1's statement dated 10/5/23 indicated, [Driver #1] was driving on my way through greenlight, suddenly had to brake, [Resident #12] went forward and hit her knee against driver seat chair. A phone interview was attempted with Driver #1, but he was unable to be reached. An interview was conducted with Resident #12 on 08/20/24 at 11:00 AM revealed on 10/05/23 she had been transported to an appointment by the transport company and on her way back to the facility, Driver #1 had secured her wheelchair in the van but forgot to secure her into her wheelchair, so when he had to make a sudden stop she fell out of her wheelchair onto the van floor. She stated Driver #1 pulled the van off the side of the road and assisted her back into her wheelchair and transported her back to the facility. Resident #12 revealed as soon as she got back to the facility, she notified the Director of Nursing (DON) and the Administrator about the fall and they asked her what happened, assessed her for injuries and at the time her left knee was swollen some and had a skin tear, but she was not in any real pain. Resident #12 revealed the fall in the van happened so fast that she didn't have time to feel scared or even think about what had happened, but she did feel that Driver #1 should have secured her into her chair especially since due to her MS diagnosis she was not able to secure herself. Review of physician order dated 10/05/23 revealed an order for a mobile x-ray to be completed on Resident #12's left ankle, left foot, left knee, left tibia (located on inside of leg, below knee joint, and forms top of ankle joint), and left fibula (located on outside of leg, below knee joint, and forms top of ankle joint). Review of on-call physician note dated 10/06/23 indicated on 10/05/23 Resident #12 had a fall from her wheelchair on transportation van. Resident #12's left knee was swollen, she complained of increased pain at a level 10 in her left knee and leg, and her x-ray results had not been received. Ibuprofen 400 mg twice daily for 3 days and Tylenol 500 mg three times daily for 3 days was ordered for Resident #12's acute pain post fall. Review of on-call physician orders for Resident #12 dated 10/06/23 indicated Ibuprofen 400 mg twice daily for 3 days for acute pain post fall and Tylenol 500 mg three times daily for 3 days for acute pain post fall. Review of a mobile x-ray dated 10/06/23 of Resident #12's left knee revealed a moderately displaced (more complex fracture because bones are out of alignment or in pieces) distal left fracture of the femur of indeterminate age (not able to determine how long-ago fracture occurred). Clinical follow-up was recommended. Review of an on-call physician note dated 10/06/23 revealed Resident #12's x-ray results were reviewed with no new treatment orders. The on-call physician indicated to continue to monitor and follow-up with the resident's primary care physician was recommended. Review of Resident #12's Medication Administration Record (MAR) from 10/6/23 through 10/8/23 revealed the following administrations of Resident #12's pain medications Tylenol 500 mg (three times daily), Ibuprofen 400 mg (twice daily), Gabapentin 300 mg (prn): -10/6/23: Gabapentin at 12:14 AM (pain level 2), Tylenol at 2:00 PM (pain level of 10), Ibuprofen at 8:00 PM (pain level 0), and Tylenol 10:00 PM (pain level of 0) -10/07/23: Tylenol at 6:00 AM (pain level 0), Gabapentin at 7:35 AM (pain level 1), Ibuprofen at 8:00 AM (pain level 0), Tylenol at 2:00 PM (pain level 0), Gabapentin at 3:24 PM (pain level 1), Ibuprofen at 8:00 PM (pain level 0), Tylenol at 10:00 PM (pain level of 2), and Gabapentin at 11:24 PM (pain level 1) -10/08/23 Tylenol at 6:00 AM (pain level 0), Ibuprofen at 8:00 AM (pain level 0), Gabapentin at 10:47 AM (pain level 1), and Tylenol at 2:00 PM (pain level of 0) Review of an on-call physician note dated 10/08/23 revealed Resident #12 complained of pain in her stomach area when inhaling and requested to be sent out to the hospital. Resident #12 was sent out from the facility to the hospital at 4:05 PM. Review of the hospital Discharge summary dated [DATE] revealed Resident #12 was seen at emergency department (ED) for a fall and shortness of breath. Resident #12 had an abrasion and edema (swelling) to the left knee and a CT scan was obtained and revealed a distal femur fracture on the left and some possible bruising to the ribs as a result of the fall. The consulting ED provider did not recommend any emergency intervention given that Resident #12 was non-ambulatory, and wheelchair bound. Resident #12 was discharged back to the facility with an order for Naproxen (treat fever and pain) 375 mg by mouth twice daily and follow-up with orthopedics. During interview with Resident #12 on 8/20/24 at 11:00 AM she revealed on the day after the fall (10/06/23), her pain had gotten worse around her left knee and the facility administered her pain medications and completed an x-ray of her left side. She stated a couple of days later (10/08/23) she started having some trouble breathing and was sent out to the hospital where they confirmed she had broken her left leg and bruised her ribs because of the fall. Resident #12 revealed the hospital administered her some more pain medication, referred her to an orthopedist, and sent her back to the facility. An interview conducted with Director of Nursing (DON) on 8/21/24 at 12:06 PM revealed she was familiar with Resident #12. She stated on the afternoon of 10/05/23, Resident #12 had returned to the facility after being transported to a medical appointment by their contract transport company and stated that she had fallen on the van. She revealed she immediately assessed Resident #12 for injury and noted a skin tear to her left knee with some swelling. The DON stated she notified physician of Resident #12's fall on 10/05/23 and received an order for a mobile x-ray of left knee. A mobile x-ray was completed on 10/06/23 and revealed a distal left leg fracture of the femur but was not able to determine the age of the fracture due to Resident #12's contractures and follow-up was recommended. She revealed the on-call physician was notified of the results and did not order any further treatment until reviewed by the facility physician. The DON stated on 10/08/23 Resident #12 was complaining of stomach pain when taking a deep breath and requested to be sent out to hospital. The on-call physician was notified, and orders were received for her to be sent out. She indicated a CT scan completed at the hospital on [DATE] revealed Resident #12 had suffered a left leg fracture of the femur and suspected bruised ribs from the fall in the van, Resident #12 returned to the facility with an order to follow-up with orthopedics outpatient. A telephone interview conducted with the physician on 8/21/24 at 4:55 PM revealed he was familiar with Resident #12 and her fall on the van. He stated he was notified on the day the accident had occurred and approved a mobile x-ray order for Resident #12's left side extremities due to her left knee showing signs of swelling. He revealed the mobile x-ray and the CT scan from the hospital both showed Resident #12 had suffered a left leg femur fracture due to the fall and recommended follow-up with outpatient orthopedic. The physician stated Resident #12 did have MS which caused her to have contractures in all of her extremities and suspected demineralization (loss of bone minerals faster than can be replaced) making it easier for injury, Resident #12 would still have had to fallen hard onto a hard surface to sustain that type of injury. He revealed he had been told by the DON that Driver #1 did not secure Resident #12 into her wheelchair causing her to fall. He indicated he would expect that all residents be secured while being transported in their wheelchairs. An interview was conducted with the Administrator on 8/21/24 at 5:27 PM revealed she was familiar with Resident #12. She stated on 10/05/23, Resident #12 had been transported by their contract transport company to an appointment. She indicated when the resident arrived back at the facility, the resident reported that during her transport back to the facility she was not secured into her wheelchair and had fallen out of her wheelchair onto the van floor. Resident #12 stated Driver #1 had stopped the van and assisted her back into her chair and brought her back to the facility. The Administrator revealed while the DON was assessing Resident #12 for injury and contacting the physician, she attempted to interview Driver #1 about the incident, but he left the facility, so she contacted the Contract Transport Company Owner to notify them about the incident. She stated the Contract Transportation Company Owner assisted her with receiving a written statement about the incident from Driver #1 and was able to view camera footage from the van to corroborate Resident #12's statement of how the fall occurred and that she had not been secured into her wheelchair. The Administrator revealed Resident #12 had suffered a left leg femur fracture and bruised ribs from the fall. She stated according to the information received from the transport company, Driver #1 was no longer employed with the company and had received prior education on securing residents and their wheelchairs during transport. A telephone interview conducted with the Contract Transport Company Owner on 8/22/24 at 9:29 AM revealed on 10/05/23, he was notified by the facility of the fall incident involving Driver #1 and Resident #12. He also revealed he received a written statement from Driver #1 and reviewed video footage from the van to confirm Resident #12's statement about the fall. He stated according to the van video footage, Driver #1 was transporting Resident #12 from an appointment back to the facility and secured Resident #12's wheelchair into the van but failed to secure her into her wheelchair by using the lap belt. He stated during this transport, Driver #1 had to stop suddenly causing Resident #12 to fall out of her wheelchair onto the van floor. He revealed after the fall, Driver #1 pulled the van over, assisted Resident #12 back into her wheelchair and transported her back to the facility. He stated Driver #1 was no longer employed with the company and all drivers received training prior to transporting on van safety and proper ways to secure residents in wheelchairs in vans. The Contract Transport Company Owner stated Driver #1 should have secured Resident #12 lap belt in her wheelchair to keep her from falling forward out of her wheelchair and once the fall had occurred, he should have stopped the van, contacted 911 and the facility, and waited for Resident #12 to be assessed by medical personnel prior to her being moved. The facility was notified of immediate jeopardy on 8/22/24 at 5:50 PM. The facility provided the following corrective action plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; The identified resident (Resident #12) is still a current Resident at the facility. Resident #12 was picked up by a contract transportation driver from a scheduled neurology appointment for transport back to the facility. Prior to leaving the appointment, the contracted driver secured Resident #12 wheelchair, but failed to secure Resident #12 seatbelt leaving her unsecured. During transport, the contracted driver had to slam on brakes causing Resident #12 to fall forward from her wheelchair into the van floor. Contracted Driver pulled off road and assisted Resident #12 back into her wheelchair and then continued to transport Resident #12 back to the facility. Contracted Driver failed to contact 911 and/or facility prior to moving Resident #12 from van floor and prior to placing her back into wheelchair after fall. The following actions after this incident: On 10/5/23, Facility initiated immediate investigation on 10/5/23. On 10/5/23, Resident #12 medical director (MD) and responsible person (RP) made aware of incident. On 10/5/23, Order obtained for x-ray to the left ankle, left foot, left knee, left tibia and left fibula. On 10/6/23, Resident #12 complained of pain on a level of 10 on a level 0-10, MD notified, and new orders obtained for the following: Ibuprofen 400mg take 1 tablet by mouth twice daily x3 days for acute pain post fall and Tylenol 500mg take 1 tab by mouth three times daily x3 days for acute pain s/p fall. Pain medication effective with a pain scale of 0 noted. On 10/6/23, x-ray results were obtained and showed the following, Left tibia/fibula- No fracture or dislocation is identified, bony structures are osteoporotic. Left ankle-No acute fracture, dislocation or osseous lesion, bony structures are osteoporotic. Left Knee- moderately displaced fracture of the distal diaphysis of the femur of indeterminate age. No dislocation is identified. Left Foot-soft tissue swelling of the foot. Bony structures are osteoporotic. No acute fracture or dislocation is identified. There is moderate hallux valgus (bony bump that forms on joint at the base of big toe), mild degenerative change of the interphalangeal (hinge shaped joint in toe) joint, first metatarsophalangeal (joint that connects toes to foot bone) joint and midfoot is present. On 10/8/2023, Resident #12 complained of pain when she inhales in her stomach area especially the left upper quad. Resident and Daughter requested for Resident to be sent out to the Hospital for Evaluation and treatment. Vital signs at that time were as follows: BP 114/72, P 68, Resp. 18, Temp. 97.8. Resident transported via ambulance and MD was notified of the transport. On 10/8/23 hospital x-ray revealed an acute comminuted (break into three or more pieces) and mildly displaced distal femoral fracture with minimal angulation. Soft tissue swelling adjacent to the fracture. A left hip gamma nail (metal implant used to stabilize fractures) seen, no dislocation. No evidence of knee joint effusion (abnormal fluid accumulation within knee joint). On 10/9/23, Resident #12 returned back to the facility via stretcher accompanied by two emergency management technicians (EMT) attendants. Resident complained of pain and discomfort to the left femur upon assessment pain meds were administered and effective. New orders from emergency department (ED) for Naproxen 375mg PO BID. Ortho follow up appointment with Orthopedic surgery as soon as possible. On 10/9/23, Facility made Resident #12 an Ortho appointment on 10/10/23 at 2:15pm. RP and MD made aware of the appointment. On 10/10/23, Resident #12 was taken to Ortho via facility transport. Ortho plan on 10/10/23 state Resident is not a strong surgical candidate given knee contracture, would not recommend a long leg cast at that time. Instead recommended a knee immobilizer and limit range of motion of including weight-bearing. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; No other Residents have had a fall/accident/or injury during a transport due to not being properly secured during transportation. Director of Nursing reviewed last 3 months of accident/incidents to ensure no other falls occurred during transport to and from the facility due to not being properly secured. Audit was completed on 10/9/23. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; An immediate in-service initiated on 10/9/23 by Maintenance Director on Q-straint system in van and how to properly secure a resident in the van, for facility transportation drivers. This education consisted of hands on and return demonstration, and verbal education. Van Drivers were educated by Administrator on ensuring Driver Transport safety checklist to be completed for all transports completed by the facility van drivers prior to leaving the facility with the resident. Education completed on 10/9/23. On 10/6/23 the contracted transportation company had a safety meeting with all drivers re-educating them on ensuring Residents are properly secured in van prior to transports Education will be added to new Transportation Driver orientation and given by the Administrator. Administrator added education to new hire orientation on 10/9/23. 4. Address how the facility plans to monitor its performance to make sure that solutions are sustained; Beginning 10/9/23, Administrator/designee will review transportation book and ensure that Driver Transport Safety checklist for all transports completed by The Ivy van drivers Monday-Friday for 12 weeks. Beginning 10/9/23, someone from Administration observed Residents that were being transported via van to ensure Resident was properly secured in van prior to leaving the facility for transport, Administration observed 5 days a week for 4 weeks, 3 days a week for 4 weeks and weekly for 4 weeks. On 10/9/23 the Administrator made the decision to take the results of the observations to the monthly Quality Assurance meeting for tracking, trending, and recommendations from the IDT team. Alleged Date of Immediate Jeopardy Removal: 10/10/23 Alleged Date of Corrective Action Completion: 10/13/23 The facility's corrective action plan was validated on 8/27/24 by the following: Interviews with facility transporters revealed they had received education on restraint system in van and how to properly secure a resident in the van as well as the driver safety checklist that was to be completed prior to leaving facility with residents. The facility transporters also stated they had to verbalize their understanding of the education they had received and complete a demonstration showing they were capable of securing residents inside the van properly for transport. The facility transporters revealed they only transported residents in manual wheelchairs inside the facility vans and any resident that required a geriatric-chair (a padded chair with a wheeled base) for transport, would have to be transported by non-emergent EMS transport and any resident with an electric wheelchair would have to be transported by their contract transport company. Contract transport company re-education dated 10/06/23 verified staff were educated on ensuring residents are secured in vans according to the manufacturer's instructions prior to transport. Review of facility orientation education for new hire transport drivers verified the education included the driver safety checklist and educational and video material on van restraint system and securing residents properly into van prior to transport. Review of the audit tools and driver safety checklist was completed with no issues noted. An observation was made on 8/23/24 of facility transporter securing a resident in their wheelchair inside the van in accordance with the manufacturer's instructions prior to being transported. Interviews were also conducted with alert and oriented residents who had been transported since October 2023 with no concerns identified. No additional transportation incidents were identified since October 2023. Interview with the Administrator revealed she had educated facility transport drivers on properly securing residents into the vans, completing van safety checklist, hands-on observations of drivers securing residents into vans prior to transport, completed audits and reviews of driver safety checklist with no issues. The Administrator also stated the facility had only transported residents with manual wheelchairs in their facility vans, residents who required a geriatric chair were transported by non-emergent EMS transport and residents with an electric wheelchair were transported by contract transport. The facility's immediate jeopardy removal date was validated as 10/10/23 and the corrective action completion date was validated as 10/13/23.