**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of manufacturer's instructions, Nurse Practitioner, family and staff interviews, the facility failed to ensure securement was according to manufacturer recommendations for providing a safe facility van transport when a resident fell out of the wheelchair onto his side on the floor of the van resulting in minor abrasions and bruising to his face, arm and side for 1 of 2 residents reviewed for accidents (Resident #22). The findings included: Review of the manufacturer's instructions for the QRT-1 Series, which is the system used on the facility's transport van to secure residents who are seated in wheelchairs during transport, specified in part: B. Secure Passenger: 1. Attach lap belts by using integrated stiffeners to feed belts through opening between seat backs and bottoms and/or armrests to ensure proper belt fit around occupant. 2) Attach shoulder belt by extending the belt over the passenger's shoulder, across upper torso and fasten pin connector onto the lap belt. Note: Combination lap/shoulder belts serve as both window-side lap belt and shoulder belt. 3) Ensure belts are adjusted as firmly as possible but consistent with user comfort. Warning: Lap and shoulder belt should not be held away from the passenger's body by wheelchair components or parts such as the wheelchair's wheels, armrests, panels, or frame. Ensure belt webbing is not twisted while being worn by passenger. Belts should always bear upon the bony structure of passenger's body and be worn low across the front of the pelvis, with the junction between lap and should belts located near the passenger's hip. Resident #22 was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or loss of strength on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #22 with modified independence for daily decision making. His speech was unclear but was usually understood and usually able to understand others. He required extensive to total staff assistance with all activities of daily living and had no impairment of the upper and lower extremities. The MDS indicated Resident #22's height was 70 inches and he weighed 182 pounds. A staff progress note dated 09/14/22 at 3:45 PM written by the Director of Nursing (DON) read in part, Nursing staff notified Resident #22 fell out of wheelchair. Resident #22 observed lying on floor on left side and left posterior upper arm. Assessment by Registered Nurse reveals Resident #22 noted to have cut on left side of face and complaining of back pain. NEURO (relating to the nerves or nervous system) checks within normal limits. Nurse Practitioner (NP) assessed resident. Orders received to transport to Emergency Department (ED) for evaluation. Resident #22's spouse aware of incident. Emergency Medical Services (EMS) notified and transported Resident #22 to the hospital. An interview was attempted with Resident #22 on 11/28/22 at 11:56 AM with his spouse at bedside. Resident #22 remained non-verbal and did not answer questions. Resident #22's spouse reported in September 2022, Resident #22 was being transported back to the facility from a dental appointment and when they arrived at the facility, the Director of Nursing (DON), Assistant Director of Nursing (ADON) and other staff were all waiting out in front of the building. She recalled as she was walking toward the van, she noticed through the window that Resident #22's wheelchair was upright but she did not see him and was thinking he had a heart attack. When she got to the door of the transportation van, the ADON and DON were already in the van and Resident #22 was on the floor. Resident #22's spouse recalled his wheelchair was still in an upward position and anchored to the floor at the back of the van and Resident #22 was lying on his side with his head next to the seat toward the front of the van. She recalled Resident #22 was examined in the transportation van by the NP who told staff not to move him and have him transported to the hospital by EMS for evaluation. Resident #22's spouse stated when they had left the dental appointment, she did not watch Nurse Aide (NA) #1 (the facility's transportation driver) secure him into the van. She was not sure how he was able to fall out of his wheelchair as he was very contracted and couldn't straighten his legs or at what point during transport he actually fell. She stated due to the fall, Resident #22 sustained a cut on the left side of the face/cheek that turned into a black eye and cut on his upper left arm. Since the incident, she spoke with the Administrator who stated it was an accident and after several conversations, neither he or the facility's Insurance Adjuster had been able to explain how or when Resident #22 fell during transport. She added the Administrator did tell her they had a plan of correction and NA #1 was reassigned back to the floor as a Nurse Aide. Also, she stated the facility had the Occupational Therapist (OT) assess Resident #22's wheelchair and they wanted to purchase Resident #22 a restraint vest to wear during transport as an extra safety measure. During a telephone interview on 11/29/22 at 12:17 PM, NA #1 stated she was the facility's transportation driver from March 2022 to September 2022 until she left the facility for other employment. NA #1 confirmed she was driving the transportation van on 9/14/22 when Resident #22 fell out of his wheelchair during transport. NA #1 explained she had transported Resident #22 to a dental office not far from the facility and after his appointment, she loaded him into the transportation van, attached the floor retractor hooks to the frame of his wheelchair and then secured the shoulder/lap belt across his chest and lap, pulled on the straps twice to make sure they were secure, and then proceeded to transport him back to the facility. She recalled when they were about 1 ½ minutes from the facility as she was slowing down to stop at the stop sign before making a turn, she heard a thud sound and when she turned around to look, Resident #22 was on the floor. She explained he had fell forward out of his wheelchair, landing on his side with his head next to the seat toward the front of the van. NA #1 stated she immediately called the facility to inform them what happened and asked staff to meet her out front of the building. NA #1 stated she was not sure how Resident #22 fell from the wheelchair and restated she had made sure he was secured in his wheelchair before starting transport, the shoulder/lap belt did not budge when the straps were pulled and the only thing that she could think might have happened was that the shoulder/lap belt must not have locked properly. NA #1 added Resident #22 was not on the floor long before she got him back to the facility, only a matter of minutes and when she arrived at the facility, the DON and other staff were waiting outside. NA #1 stated later that day, the Administrator and DON asked her to explain what had happened but did not have her do a reenactment of how she loaded and secured Resident #22 into the transportation van. NA #1 stated the following day (09/15/22), she received reeducation from the Maintenance Director regarding proper securement when transporting residents in the facility van. The NP progress note dated 09/14/22 revealed in part, asked to come outside to transport van to assess Resident #22. Resident #22 observed lying on his left side on the floor of the van. Resident #22 verbalizes 'mmhmm which equals 'yes' to back and head pain. Left cheek area with small abrasion and bleeding. Unable to obtain vitals due to positioning .normocephalic (referring to a head of normal shape and size) appearing and to palpation (touch) .bilateral contractures of the extremities .no neurological appearing acute deficits, responds to spouse and answers questions in his own usual way .Assessment/Plan: fall from wheelchair during transport returning from dental appointment. Instructed nursing staff to stabilize Resident #22's head and not to move given complaints of back and head pain. Send to Emergency Department (ED) for further evaluation. During an interview on 12/01/22 at 10:28 AM, the NP recalled on 09/14/22, staff came into the facility to get her and ask her to come out to the transportation van to assess Resident #22. She stated when she got outside, the side door of the van was open and she had a clear visual of Resident #22 who was lying on his left side on the floor with his head up toward the front of the van. The NP stated she was not sure how Resident #22 fell out of his wheelchair and thought maybe his wheelchair was positioned in the middle of the van but couldn't really state for sure where it was located as her main focus at the time was to ensure Resident #22 was ok. She recalled Resident #22 was alert and able to say mmhmm to questioning, had a small abrasion on his cheek that was bleeding and he complained of pain so she told staff not to move him and call EMS to transport him to the hospital for evaluation. The EMS report dated 09/14/22 noted upon arrival at the skilled nursing facility, Resident #22 was lying on his left side in the transportation van. The EMS report read in part, Per staff on scene, it is unknown how long the patient has been laying in the back of the van and when the van arrived at their facility, the patient was on the floor. Patient noted to be conscious, alert and oriented to his normal per family on scene. Patient noted to be non-verbal. Patient noted to be complaining of pain in his lower back. Unable to place the patient in a C-collar (medical device used to support the neck) due to the patient having a short neck. Stabilized the patient's neck via manual c-spine and rolled patient onto his back. Patient noted to have a laceration to the upper posterior area of his left arm from where he laid on a latch in the back of the van and an abrasion below his left eye. Placed the patient on a backboard and carried him to the stretcher. Wrapped the patient's laceration to his arm, placed towels around the patient's head for stabilization and transported to the hospital. The ED physician progress note dated 09/14/22 read in part, History: Patient arrives via EMS due to injury. Patient with a history of intracerebral hemorrhage (type of stroke caused by bleeding within the brain tissue) three and a half years ago which has left patient completely bedridden and contracted. Spouse at bedside states that he left his dentist appointment and was placed in the transportation van but when they arrived at the facility everybody came rushing out of the facility to the van. When she got to the van, she found Resident #22 on the floor of the van on his left side. Wheelchair was still strapped in the back of the van. Patient arrives with an abrasion to the left cheek and to the left upper arm. There are abrasions and bruising noted to the left lateral side and left hip area. Patient is able to answer yes and no questions. Complains of pain to the lumbar spine with palpation as well as to the left hip with palpation. Patient is contracted with legs bent towards the torso, unable to fully extend. Assessment/Plan: skin tears cleaned and bandages applied. Skin tear to left inner arm consistent with sliding on floor. It was further noted x-rays conducted on 09/14/22 of Resident #22's lumbar spine and left hip were negative for acute fractures. Resident #22 was discharged from the hospital on [DATE] back to the skilled nursing facility in stable condition. A staff progress note dated 09/15/22 at 8:00 AM written by the Assistant Director of Nursing (ADON) read in part, Resident #22 awake and alert per baseline this AM with spouse at bedside. Skin assessment reveals skin tear to left upper posterior arm approximately 2 centimeters (cm) x 1 cm x 0.1 cm with scant serous drainage (thin, watery and clear substance exiting the wound), no redness, no odors. Left uppermost posterior arm presents with superficial abrasion approximately 5 cm x 1 cm x 0 cm without drainage, no redness or signs of infection. Left elbow with superficial abrasion approximately 1 cm x 1 cm x 0 cm, no redness or drainage. Light purple/red bruising to left forearm approximately 2.5 cm x 2 cm x 0 cm, skin intact. Left facial cheek presents with superficial abrasion approximately 0.25 cm x 1 cm x 0 cm, no drainage or redness. [NAME] presents with superficial abrasion approximately 0.2 cm x 0.3 cm x 0 cm, no drainage, no redness. Resident #22 status post fall from yesterday 9/14/22 without any latent injuries observed, moves all extremities within baseline, neuro checks in place and ongoing, within normal limits per baseline. Resident #22 complains of general mild discomfort with new order for Tylenol 500 milligrams (mg) 2 tablets every 6 hours as needed for pain/discomfort administered. Vital signs stable, no signs/symptoms of distress. During an interview on 11/30/22 at 9:17 AM, the Assistant Director of Nursing (ADON) stated on 09/14/22, when he went outside to the front of the building with the DON, he saw the transportation van coming up the road with Resident #22's spouse following the van in her car. As soon as the van parked, he and the DON opened the side door and saw Resident #22 lying on the floor on his left side. The ADON stated Resident #22 was alert and appeared calm and upon assessment he didn't have any significant bleeding, however, they decided not to move him as they weren't sure if he had any injuries that were not visible and wait for EMS to arrive to get him on the backboard to take him to the hospital for further evaluation. The ADON stated when he opened the door of the van, Resident #22 was lying on the floor in front of his wheelchair that was still secured to the floor van with his head next to the seat toward the front. He stated the wheelchair was still in an upright position and the shoulder/lap belt was pulled from the side with the strap caught around the armrest on the left side of the wheelchair and was not sure what happened or how it came loose. The ADON stated Resident #22 did not have any purposeful movement, was contracted and would not have been able to use his hands to unbuckle the shoulder/lap belt. During an interview on 12/01/22 at 2:26 PM, the Maintenance Director recalled on 09/14/22, he was in the maintenance building behind the facility when he got a call and was told to come to the front of the facility with tools to remove the front seats of the transportation van. He stated when he arrived, staff were outside by the van, the side door was open and he saw Resident #22 on the floor of the van lying on his left side with his head up toward the driver's seat. The Maintenance Director recalled he had to remove Resident #22's wheelchair from the transport van for EMS to get into the van to assist Resident #22. He recalled Resident 22's wheelchair was in an upright position, the shoulder/lap belt was not engaged and the floor securement retractor straps were intact and connected to the frame of the wheelchair. The Maintenance Director stated the van was placed out of service pending a safety inspection from an outside company; however, he also checked the securement system thoroughly and found nothing out of the ordinary. The Maintenance Director confirmed he provided NA #1 with reeducation on wheelchair securement after the van accident involving Resident #22 which included NA #1 providing a return demonstration. In addition, he had since trained the new facility transportation driver that also included a return demonstration for proper securement. An observation of the facility transportation van and follow-up interview was conducted with the Maintenance Director on 12/01/2 at 2:40 PM. The facility transportation van was a mid-size van with a lift located at the back of van. When the side door on the right side of the van was opened there were 2 shoulder/lap belts (approximately a wheelchair apart) attached to the roof of the van on the left side of the van, 2 buckle straps on the right side for the shoulder/lap belt to connect to when pulled across the resident seated in the wheelchair and on the floor were retractor with straps that had hooks to connect to the bottom of the wheelchair frame. The Maintenance Director stated on 09/14/22, Resident #22's wheelchair was positioned in the middle of the van toward the back closest to the lift. From the wheelchair to the seat (pushed up flush to the back of the driver's seat) was approximately 2 feet of space which was where he stated Resident #22 landed when he came out of the wheelchair onto his left side. He explained Resident #22's head was close to the seat located directly behind the driver's seat, up next to the left wall of the van and there was a floor retractor that Resident #22's left arm landed on. The Maintenance Director stated when he first observed Resident #22's wheelchair and removed it from the transportation van, the shoulder/lap belt was not engaged. He explained the buckle strap to the right of the wheelchair was lying on the floor, the shoulder/lap belt was positioned to the left at home base which he described as not pulled from its original position and the shoulder/lap strap was not caught on the arm rest of the wheelchair. A joint interview was conducted with the Administrator and DON on 11/29/22 2:00 PM. The DON stated she was informed by facility staff that NA #1 was on her way back to the facility and had called to report Resident #22 had fallen out of his wheelchair during transport. The DON stated she called the Administrator to notify him of the situation as she walked outside to meet NA #1 upon their arrival and less than 5 minutes passed before the transportation van pulled up to the facility. The DON recalled when she and the ADON opened the side door of the van, Resident #22 was lying on his left side on the floor. Upon assessment, she stated Resident #22 was alert and responding per his baseline. The DON explained the way Resident #22 was lying on the floor it appeared as if he somehow leaned forward toward the front of the van and came out of the wheelchair. She added Resident #22 was not able to move his upper extremities on command but would move around at times, although very limited. The DON recalled NA #1 was very distraught and trying to explain what happened but the DON could not recall what NA #1 said as her main concern at the time was ensuring Resident #22 was ok. The DON stated when she assessed Resident #22 she noticed a small laceration on his left cheek that was bleeding and a skin tear on his upper arm. She added the NP also assessed Resident #22 the best she was able given his positioning on the floor of the van. She stated Resident #22 was not moved or repositioned until EMS arrived to transport him to the hospital and as EMS got him on the backboard she observed other abrasions to his arm where he had laid on the floor. The DON restated her focus was on Resident #22 and did not observe the securement of his wheelchair but did state the shoulder/lap belt was not on Resident #22 when he was on the floor of the transportation van. A joint interview continued with the Administrator and DON on 11/29/22 2:00 PM. The Administrator stated he was not at the facility when notified by the DON that NA #1 had called the facility to report Resident #22 had fallen out of his wheelchair during transport. By the time he arrived back to the facility, the transportation van was already parked at the front of the building and staff were outside assessing the situation. The Administrator recalled Resident #22's wheelchair was positioned upright and the floor securement retractors were attached to the frame of the wheelchair. The Administrator stated immediately after Resident #22 was transported to the hospital, he and the DON sat down with NA #1 to ask her what happened and she had described the steps she had done to ensure Resident #22 was secured in his wheelchair prior to transport. The Administrator stated they did not have NA #1 conduct a reenactment of how she secured Resident #22 into his wheelchair and explained she had been in the position since February 2022 and transported a lot of residents to outside appointments without incident. The Administrator stated they were unable to determine the root cause of Resident #22's fall and explained maybe the movement of the transportation van caused the shoulder/lap belt to come loose or the buckle malfunctioned. He added it was hard to determine what actually happened as Resident #22 could not tell them and they only had NA #1's account of the incident. During a follow-up interview on 11/29/22 at 3:50 PM, the Administrator explained after the incident on 09/14/22, they implemented a plan of correction which included placing the facility transportation van out of service until thoroughly checked by an outside company, utilizing an outside transportation company for resident appointments until the facility van was placed back into service on 09/21/22 and monitoring systems for ensuring a safe transport. He added NA #1 did not do any further transport and the new Transportation Driver was educated on proper securement by the Maintenance Director, who was also the backup transportation driver. On 11/29/22 at 4:44 PM, the Administrator and Director of Nursing were notified of Immediate Jeopardy. The facility provided the following Allegation of Compliance with the correction date of 09/15/22: Based on incident dated 09/14/22, Resident #1 was being transported back to the facility from a dentist appointment when Resident #1 slid out from his wheelchair to the floor of the van. 1. For the Resident affected: Driver notified facility immediately. Resident #1 was not moved from his position until Emergency Medical Services (EMS) arrived. Nurse Practitioner was notified and assessed Resident #1. Orders received to transport Resident #1 to the Emergency Department for evaluation. Resident #1 was transported to the hospital by EMS. 2. For the Residents with the potential to be affected: Services were immediately suspended with facility transportation by the Administrator on 09/14/22 pending investigation of the incident. The transportation van was taken to an outside company first thing on the morning of 09/15/22 for a full safety inspection. The driver was re-educated on 09/15/22 upon returning to work on Van Safety and Van lift check off. Additionally, transportation drivers were educated on defense driving on 09/15/22. Resident #1's wheelchair was screened for positioning by the building's Occupational Therapist. 3. Systematic Change: Education was provided to all in-house transport drivers by the Administrator on the proper securement of residents while riding in a wheelchair accessible van on 09/15/22. Education included pre-securement steps, securement steps, and final check sections. Safety inspection sheets will be used and monitored by facility designee. 4. Monitoring: Facility designee will observe loading and unloading of resident to ensure proper securement of residents in the vehicle. Also, safety inspection sheets will be monitored by facility designee. Audit will be done 3 days a week times 2 weeks, then 2 days a week times 2 weeks, then two times a week times 2 months. Additionally, Resident #1 will be assigned a designee to ride with them on their next 5 transportations to ensure Resident #1's positioning is secure. Starting on 09/15/22, data obtained during the auditing process will be analyzed for patterns and trends and reported to the Quality Assurance and Performance Improvement (QAPI) by the Administrator monthly for two months. At that time, the QAPI committee will evaluate the effectiveness of the interventions to determine if continued auditing is necessary to maintain compliance. Alleged date of compliance: 09/15/22. The facility's Allegation of Compliance was validated from 11/29/22 to 12/01/22 and concluded the facility implemented an acceptable corrective action plan effective 09/15/22. It was confirmed all authorized drivers were trained on wheelchair securement and a transport driver skills assessment was completed with NA #1 by the Maintenance Director on 09/15/22. The facility provided documentation that included monthly safety inspections of the facility transportation van, Transport Drivers training and facility audits. The transportation audit sheets that were started on 09/21/22 when the facility transportation van was placed back into service were reviewed with no concerns identified and remained ongoing. Residents who were transported to outside appointments were interviewed and reported no concerns. Facility staff were interviewed and confirmed they received training on transportation safety that included how to properly secure a resident in the wheelchair and perform return demonstrations. The corrective action plan was reviewed by QAPI on 10/21/22 and 11/17/22.