**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of surveillance video, and interviews with staff, Nurse Practitioner (NP) and Medical Director (MD), the facility failed to assess Resident #287 immediately after a fall from the contracted transportation van. On 12/12/22 Resident #287 was rolled out of the back of the contracted transportation van in her wheelchair and fell to the ground landing on her left side and hitting the back of her head. The Contracted Transporter lifted Resident #287 back into her wheelchair and wheeled her into the facility without being assessed by a licensed professional. The Resident complained of mid back pain at 7 out of 10 (10 being the worst pain) and bruising was noted on her right forearm. Resident #287 was sent to the emergency department for evaluation and diagnosed with a compression fracture of the L1 vertebrae. There is the high likelihood of further injury when a resident is moved after a fall before being assessed by a licensed professional. This deficient practice occurred for 1 of 3 residents review for accidents (Resident #287). Immediate Jeopardy began on 12/12/22 when the Contracted Transporter lifted Resident #287 from the ground back into her wheelchair even after being instructed by a staff member not to move the Resident. Immediate Jeopardy was removed on 6/28/23 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 with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Findings Included: Resident #287 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease with dialysis dependency and diabetes mellitus type 2. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #287 was cognitively intact and required extensive assistance with transfers and was receiving dialysis during the assessment lookback period. A review of a transportation contractor document titled North Carolina Department of Transportation (NCDOT) integrated Mobility Division: Minimum Training Standards dated January 2022 read in part training must be conducted with new hires and annually thereafter as refreshers training with re-certification. Training topics included wheelchair/mobility device training, securement, emergency procedures for medical emergencies, accident or incident reporting procedures, and lift/ramp inspection and operation. The contracted van driver completed these trainings upon hiring. Review of an incident report dated 12/12/22 at 11:36 AM completed by Nurse #3 read in part, Nurse #3 was called to the front of the building and informed that a resident had fallen from her wheelchair onto the lift. Resident #287 stated she had fallen while being escorted from the transport van by the Contracted Transporter. Resident #287 had a small bump to the back of her head. She also had some bruising to her right forearm and complained of mid back pain 7 out of 10. A review of the facility's security video with the Administrator occurred on 6/27/23 at 2:30 PM. The video footage did not contain sound and was partially obscured as Resident #287's wheelchair was seen tumbling from the back of the contracted transportation van without Resident #287 in it. The van's opened back doors partially obstructed the view of the accident and Resident #287 was unable to be viewed falling out of the wheelchair and hitting the grounded gate lift. The video footage showed Resident #287 lying on the grounded lift gate of the van with the Contracted Transporter soon after arriving to Resident #287. Nurse Aide (NA) #3 comes into to view and was seen speaking with the Contracted Transporter and then entering the facility as the Contracted Transporter picked up Resident #287 underneath the arms and placed her into the wheelchair. The Contracted Transporter pushed Resident #287 into the facility. Resident #287 was seen entering the facility without any visible blood and pointing at the back of her head and did not appear to be in distress. A review of the statement signed by the Contracted Transporter dated 12/12/22 read in part, I was unloading Resident #287. While unloading the lift was unfolded without my knowledge, I pushed her out and she fell to the ground. I immediately got down to see if she was okay. Never lost consciousness. She stated she was okay. Got her back in the chair. Again, asked if she was okay, she stated she was still okay. I parked the van and came straight inside. Happened around 11:30. Struck the right side of body. The Contracted Transporter was unable to be interviewed due to no phone contact information. Resident #287 was discharged from the facility 1/7/23 and was unable to be interviewed. The facility's Transportation Supervisor was interviewed on 6/30/23 at 9:10 AM. The Transportation Supervisor reported contracted transporters were not trained or educated by her or the facility. Contracted transporters were trained and certified by the company they worked for, and the Contracted Transporter received his training from the NCDOT as required for hiring. The Contracted Transportation Supervisor was interviewed via telephone on 6/27/23 at 3:30 PM. She confirmed the Contracted Transporter had received his NCDOT training before he was allowed to transport residents. The Contracted Transportation Supervisor stated she could not give any other information. An interview was conducted with NA #3 on 6/26/23 at 1:53 PM. She stated she observed Resident #287 lying on her left side in the fetal position on the ground behind the van as she entered the parking area returning from her break. The resident's wheelchair was located behind and to the side of lift gate. NA #3 explained she spoke to the Contracted Transporter and instructed him to not move Resident #287 as she was going to find assistance from inside the facility. She observed the Contracted Transporter in the process of moving the resident from the ground but did not observe the Contracted Transporter placing the resident back into the wheelchair. Nurse #3 was interview on 6/27/23 at 1:40 PM and stated he was paged overhead by the receptionist to go to the front of the building because a resident had fallen from a transportation van. The Resident was in the front lobby of the facility sitting in her wheelchair when he arrived, and the Contracted Transporter said he was not paying attention to the resident, and she fell out of the van. Nurse #3 stated he assessed Resident #287 in her room who was alert and talking with complaints of intermittent pain in her back and indicated she hit the back of her head. A review of the Nurse Practitioner (NP) assessment note dated 12/12/22 read in part Resident #287 was returning to the facility from dialysis. The driver of the transit van apparently dropped the patient (Resident #287) from the lift. He (van driver) picked the patient up and put her into the wheelchair to bring her back into the facility. The patient is complaining of acute low back pain. Pain is increased with any movement of her legs. She did hit the back of her head and has a small abrasion or contusion with complaints of a headache. Resident to be transferred to the ED for evaluation. An interview with the NP was conducted on 6/28/23 at 9:33 AM. The NP stated had assessed the resident when the resident returned to her unit after the fall from the contracted transportation van. The resident appeared uncomfortable and had told her she had been dropped and the Contracted Transporter picked her up and put her back into the wheelchair. The NP stated that Resident #287 could have had more injury because the Contracted Transporter had moved the resident without being assessed by a licensed staff first. A review of Emergency Department (ED) notes dated 12/12/22 revealed the patient 's chief complaint was a fall. The patient reported sharp shooting pain back of her head and lumbar spine, non-radiating, constant, and worse with motion. The patient denied any neck pain. The ED diagnostic imaging found a 50% compression of L1 (lumbar) vertebral body. The ED plan of care recommended supportive care measures with a primary care physician follow-up. Resident #287 was provided one tablet of oxycodone 325 MG (pain medication) while in the ED. She discharged from the ED on 12/12/22 and sent back to the facility. The Medical Director (MD) was interviewed on 6/30/23 at 10:10 AM. He stated that in general moving a resident without a licensed professional assessing them could result in further injury. The Administrator was interviewed on 6/26/23 at 1:53 PM. She reported she was notified immediately on 12/12/22 when Resident #287 had fallen from a contracted transportation van in the parking lot and went to the front entrance of the building. The Contracted Transporter had picked up the resident and placed her into the wheelchair before licensed staff could assess her. The resident's assigned nurse, Nurse #3, was called to the front to assess and take Resident # 287 to her room. The NP was in the facility, assessed the resident and sent the resident to the ED for evaluation. Resident #287 had a fractured L1 vertebrae from the accident. The Administrator stated the Contracted Transporter was interviewed and the security video footage was reviewed to see the cause of the accident. The Administrator stated the facility initiated an investigation immediately and was able to get a written statement and an interview from the Contracted Transporter before he left. The Contracted Transporter stated he pushed Resident #287 out of the van, and she fell to the ground. The Contracted Transporter immediately got down from the van to check if she was ok. The Contracted Transporter reported Resident #287 reported to him she was ok, and he placed her back into her wheelchair and he pushed her inside the building. The Administrator was notified of Immediate Jeopardy on 6/26/23 at 6:10 PM The facility provided the following Credible Allegation of immediate Jeopardy removal: 1. The facility immediately conducted an action plan to address contract transportation services with post-accident policies to include assessment. Included in this action plan was but not limited to: o On 12/12/2022 - 12/15/2022 we worked with the contracted transportation company to ensure training of all contract drivers that provide services to Skyland Care Center including the individual involved in the accident. I spoke directly with the supervisor about the driver moving the resident before our nurse came to assess. She informed me that she was doing an internal investigation, and this was against their companies' procedures and the driver should have immediately called 911 after the incident. She informed me that the driver was in-serviced on this procedure and if allowed to continue employment, he would be in-serviced again. I also requested training with contracted drivers to notify the facilities front desk staff prior to assisting residents from vehicles to ensure the transfer is completed safely. The driver was not allowed to drive any facility residents if the contracted company allowed his employment going forward. o On 12/15/2022 the administrator in-serviced all front reception employees to locate a CNA/Nurse when transit notified them, they were in the parking lot. They were to go to the transit vehicle and stand beside the lift to assure the residents are unloaded safely. As of March 20, 2023, we no longer use a contracted agency for transportation and all transportation is performed in house unless the resident needs stretcher service and then they are transported per EMS. 2. The facility terminated its transportation contract in March 2023 and no longer has an outside transport company they currently use. 3. On 6/26/2023 the Administrator and Staff Development RN conducted an in-service for all employees on what to do if they witness a resident fall. Staff will not be allowed to complete a shift before completion of the training. In addition, the orientation process was reviewed, and reporting accidents and proper assessing was already part of the orientation process and will continue as part of initial facility education and orientation. The education included: a. Call for a nurse to evaluate for possible injuries (DO NOT MOVE THE RESIDENT UNTIL ASSESSED BY A NURSE). b. Obtain vital signs as soon as safe to do so. c. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. d. Notify residents attending physician and family in an appropriate time frame. e. Report violations of these procedures to the Administrator. 4. Training for all in-house transportation staff was started on 6/27/2023 by the Transportation Director. Transportation staff will not be allowed to drive the van until they have completed the in-service. The in-service included reviewing pictures posted in facility van showing the proper way to load/unload residents and re-reviewed the signage posted in the van citing the steps to take if incident/accident happens in route. These steps include 1. Call 911, 2. DO NOT MOVE RESIDENT UNTIL ASSESSED BY EMERGENCY OFFICIALS, 3. Call Administrator, 4. Call facility to send nurse to the scene, and 5. Wait for further instructions. This was recently in-serviced in our annual October 2022 in-service. 5. The Administrator is responsible for all issues related to immediate jeopardy removal. Alleged IJ removal date: 6/28/23 On 6/30/23 the facility's plan for Immediate Jeopardy removal effective 6/28/23 was validated by the following: Documentation and interviews with staff. Review of the in-service sign in sheets revealed all facility staff received education on what to do if they witness a resident fall. Staff who worked in each department and on all shifts were interviewed. Interviewed facility staff reported they should not move a resident who had fallen before the resident could be assessed by a nurse. Interviewed licensed facility staff reported after the resident had been assessed by a nurse, vitals would be taken, first aid or medical treatment would be administered if appropriate, and the attending physician and family would be notified as soon as possible. Interviewed transportation staff stated if a resident fell during transport, 911 would be called immediately, the resident would not be moved until assessed by emergency officials, the Administrator and facility would be called. The transportation staff stated instructions for actions to take if an accident or incident occurs were posted in the van. The transportation guide instructions were observed accessible in the vans along with posted photographs demonstrating residents facing out of the van when unloading. The facility no longer uses any contracted van services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, video surveillance review, and staff and Nurse Practitioner interviews the facility contracted van driver failed to ensure the lift gate was in the elevated position before unloading a resident from the back of a facility contracted van. On 12/12/22 Resident #287 was rolled out of the back of the contracted transportation van in her wheelchair and fell to the ground landing on her left side and hitting the back of her head. The Resident complained of mid back pain at 7 out of 10 (10 being the worst pain) and bruising was noted on her right forearm. Resident #287 was sent to the emergency department for evaluation and diagnosed with a compression fracture of the L1 vertebrae. This occurred for 1 of 3 residents sampled for accidents (Resident #287). Immediate Jeopardy began on 12/12/22 when Resident #287 was rolled out of the back of the contracted transportation van in her wheelchair and fell to the ground. Immediate Jeopardy was removed as of 6/28/23 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 with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: Resident #287 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease with dialysis dependency and diabetes mellitus type 2. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #287 was cognitively intact and required extensive assistance with transfers and was receiving dialysis during the assessment lookback period. She used a wheelchair and a walker for mobility. Review of a facility document titled Transportation Service Agreement for the transit contractor dated July 1, 2022, through June 30, 2023, read in part that the contractor agrees to comply with all applicable federal and state regulations concerning human services. Furthermore, the contractor is responsible for ensuring the drivers are trained in defensive driving and in wheelchair securement. A review of a transportation contractor document titled North Carolina Department of Transportation (NCDOT) integrated Mobility Division: Minimum Training Standards) dated January 2022 read in part training must be conducted with new hires and annually thereafter as refreshers training with re-certification. Training topics included wheelchair/mobility device training, securement, and lift/ramp inspection and operation. The contracted van driver completed these trainings upon hiring. Review of an incident report dated 12/12/22 at 11:36 AM completed by Nurse #3 read in part, Nurse #3 was called to the front of the building and informed that a resident had fallen from her wheelchair onto the lift. Resident #287 stated she had fallen while being escorted from the contracted van by the Contracted Transporter Resident #287 had a small bump to the back of her head. She also had some bruising to her right forearm and complained of mid back pain 7 out of 10. A review of the facility's security video with the Administrator occurred on 6/27/23 at 2:30 PM. The video footage did not contain sound and was partially obscured as Resident #287's wheelchair was seen tumbling from the back of the contracted transportation van without Resident #287 in it. The van's opened back doors partially obstructed the view of the accident and Resident #287 was unable to be viewed falling out of the wheelchair and hitting the grounded gate lift. The video footage showed Resident #287 lying on the grounded lift gate of the van with the Contracted Transporter soon after arriving to Resident #287. Nurse Aide (NA) #3 comes into view and was seen speaking with the Contracted Transporter and then entering the facility as the Contracted Transporter picked up Resident #287 underneath the arms and placed her into the wheelchair. The Contracted Transporter pushed Resident #287 into the facility. Resident #287 was seen entering the facility without any visible blood and pointing at the back of her head and did not appear to be in distress. A review of the statement signed by the Contracted Transporter dated 12/12/22 read in part, I was unloading Resident #287. While unloading the lift was unfolded without my knowledge, I pushed her out and she fell to the ground. I immediately got down to see if she was okay. Never lost consciousness. She stated she was okay. Got her back in the chair. Again, asked if she was okay, she stated she was still okay. I parked the van and came straight inside. Happened around 11:30. Struck the right side of body. The Contracted Transporter was unable to be interviewed due to no phone contact information. Resident #287 was discharged from the facility 1/7/23 and unable to be interviewed. The Contracted Transportation Supervisor was interviewed via telephone on 6/27/23 at 3:30 PM. The Supervisor reported that the Contracted Transporter was no longer employed with the company. The Supervisor stated she was notified by the facility Administrator immediately after the accident occurred on 12/12/22. The Supervisor did not remember the specific day or time the Administrator had called to inform the plan of correction the facility had put into place. The Supervisor confirmed the Administrator had informed her the plan was that the transportation company van drivers would notify the facility upon arrival and wait for a facility staff to be present when unloading a resident. The Supervisor stated and she was unable to share any additional information. The facility's Transportation Supervisor was interviewed on 6/30/23 at 9:10 AM. The Transportation Supervisor reported contracted transporters were not trained or educated by her or the facility. Contracted transporters were trained and certified by the company they worked for, and the contracted van driver received his training from the NCDOT as required for hiring. Furthermore, the Transportation Supervisor stated the facility drivers did not load and unload a resident without additional trained assistant present. The residents were never unloaded facing the front of the van and always had a staff member in direct contact with the wheelchair during the process with a staff in the van and one on the ground. An interview was conducted with NA #3 on 6/26/23 at 1:53 PM. She stated she observed Resident #287 lying on her left side in the fetal position on the ground behind the van as she entered the parking area returning from her break. The resident's wheelchair was located behind and to the side of lift gate. NA #3 explained she spoke to the Contracted Transporter and instructed him to not move Resident #287 as she was going to find assistance from inside the facility. She observed the Contracted Transporter in the process of moving the resident from the ground but did not observe the Contracted Trasporter placing the resident back into the chair. NA #3 said Resident #287 did not appear in distress and was not yelling or crying. Nurse #3 was interview on 6/27/23 at 1:40 PM and stated he was paged overhead by the receptionist to go to the front of the building because a resident had fallen from a transportation van. The Resident was in the front lobby of the facility sitting in her wheelchair when he arrived, and the Contracted Transporter said he was not paying attention to the resident, and she fell out of the van. Nurse #3 stated he assessed Resident #287 in her room who was alert and talking with complaints of intermittent pain in her back and indicated she hit the back of her head. Nurse #3 explained the NP was in the facility and had the resident sent to the emergency department (ED). A review of the Nurse Practitioner (NP) assessment note dated 12/12/22 read in part Resident #287 was returning to the facility from dialysis. The driver of the transit van apparently dropped the patient (Resident #287) from the lift. He (van driver) picked the patient up and put her into the wheelchair to bring her back into the facility. The patient is complaining of acute low back pain. Pain is increased with any movement of her legs. She did hit the back of her head and has a small abrasion or contusion with complaints of a headache. Resident to be transferred to the ED for evaluation. An interview with the NP was conducted on 6/28/23 at 9:33 AM. The NP stated had assessed the resident when the resident returned to her unit after the fall from the contracted transportation van. The resident had low back pain and when moving her legs. The resident was complaining of a headache as she had hit the back of her head and had a bruise to her right arm. The resident did not lose consciousness, was alert and was not bleeding. The resident appeared uncomfortable and had told her she had been dropped and the Contracted Transporter picked her up and put her back into the wheelchair. The NP reported the resident returned to the facility with a diagnoses of a lumbar compression fracture. A review of Emergency Department (ED) notes dated 12/12/22 revealed the patient's chief complaint was a fall. The patient reported sharp shooting pain back of her head and lumbar spine, non-radiating, constant, and worse with motion. The patient denied any neck pain. The ED diagnostic imaging found a 50% compression of L1 (lumbar) vertebral body. The ED plan of care recommended supportive care measures with a primary care physician follow-up. Resident #287 was provided one tablet of oxycodone 325 milligrams (narcotic pain medication) while in the ED. She discharged from the ED on 12/12/22 and sent back to the facility. The Administrator was interviewed on 6/26/23 at 1:53 PM. She reported she was notified immediately on 12/12/22 when Resident #287 had fallen from a contracted transportation van in the parking lot and went to the front entrance of the building. Resident #287 was sitting in her wheelchair inside the front door of the facility. The Administrator indicated no one witnessed the fall but the Contracted Transporter and that NA #3 had seen Resident #287 lying on the ground behind the van as she entered the parking area. The resident's assigned nurse was called to the front to assess and take Resident # 287 to her room. The NP was in the facility, assessed the resident and sent the resident to the ED for evaluation. Resident #287 had a fractured L1 vertebrae from the accident. The Administrator stated the driver of the contracted transportation van was interviewed and the security video footage was reviewed to see the cause of the accident. The Contracted Transporter had reported he did not know the lift gate was on the ground when he was unloading Resident # 287 and he pushed her out the back of the van causing the accident. The Administrator stated the facility initiated an investigation immediately and was able to get a written statement and an interview from the Contracted Transporter before he left. The Contracted Transporter reported to the Administrator while unloading Resident #287, the lift was unfolded without his knowledge. The Contracted Transporter stated he pushed Resident #287 out of the van, and she fell to the ground. The Contracted Transporter immediately got down from the van to check if she was ok. The Contracted Transporter reported Resident #287 reported to him she was ok, and he placed her back into her wheelchair and he pushed her inside the building. The Administrator indicated he spoke with the Contracted Transportation Supervisor and who stated the Contracted Transporter involved with the accident on 12/12/22 would not be allowed to transport any more residents from the facility. The Contracted Transportation Supervisor informed the Administrator all training for contracted transporters was completed, and up to date with Department of Transportation (DOT) standards. The facility put a new process in place on 12/15/22 and the contracted transporters would notify the facility when a resident returned to the facility. A staff member would be present when residents are being unloaded from the van and stand near the van lift to assure the residents are brought down safely. The Administrator concluded with the front door staff (reception) had been in-serviced on the procedure. The Administrator was notified of Immediate Jeopardy on 6/26/23 at 6:10 PM The facility provided the following Credible Allegation of immediate Jeopardy removal: 1. Review of the incident and accident and completion of root cause analysis to identify if the facility could have prevented the fall. In review of this incident, the facility felt the facility could not have done anything else to prevent the fall from occurring as the facility was using an outside contractor service and the driver involved had been properly trained on proper transfer of residents on and off the van. The facility was provided with training that was conducted by the outside company for their drivers and proper use of lifts is part of that training. In this incident, the van driver simply forgot the position of where he had left the lift and made a mistake. 2. The facility immediately reported the Transportation Driver to his employer and demanded review of the situation and corrective actions. The facility requested all documentation from the transportation company. The transport company refused to release the actual training for the driver. They did send a blank copy of the DOT training that all drivers complete. The supervisor did verify verbally that training was up to date for the driver. 3. The facility immediately conducted an action plan to address contract transportation services with post-accident policies. Included in this action plan was but not limited to: o Working with the Transportation Company to ensure training of all contract drivers that provide services to Skyland Care Center to include the individual involved in the accident. This training includes a request to the transport company alert facility staff prior to assisting residents from the van to stand by and monitor the safety of the transfer. The driver involved in the accident was not allowed to transport any facility residents if he was allowed to continue employment with the transportation company. o Systemic changes were as follows: Facility put in place that a facility CNA/Nurse must be present when a contracted company employee unloads a resident from their transport vehicle. We no longer use outside transport companies as of March 20, 2023. In addition to the steps taken in December 2022 and ongoing to prevent adverse outcomes, and following review that this was an isolated conduct issue of a contracted employee, the Facility has taken and/or modified the necessary steps required by the state operations manual to provide a credible allegation of compliance. 1. The facility terminated its transportation contract in March 2023 and no longer has an outside transport company they currently use. 2. Facility drivers will be in-serviced starting on 6/27/2023 by the Director of Transportation on the facility lift and safety procedures in accordance with the manufacturers' specifications and will demonstrate competency. Transportation drivers will not be allowed to drive the van until they have completed the training. The transportation director is keeping track of the training. The transportation drivers were educated that the staff member and resident should be facing out when taking a resident out of the van onto the lift gate. Pictures are posted in the van indicating this. 3. In the future if contract transportation services, are used by the facility, they will be required to provide the same training for their employees and provide documentation of the training for each driver who provides services for the facility before they can transport residents. If they refuse, we will not contract with this company. 4. The Administrator is responsible for all issues related to immediate jeopardy removal. Alleged IJ removal date: 6/28/23 On 6/30/23 the facility's plan for Immediate Jeopardy removal effective 6/28/23 was validated by the following: Documentation and interviews with staff. Review of the in-service sign in sheets revealed all transportation staff received education and training of the facility van lifts and safety procedures. Interviewed transportation staff reported they follow the guide instructions posted in the transport vans for operating the lift, securing the wheelchairs and what actions to take if an accident or incident occurs. The transportation guide instructions were observed accessible in the vans along with posted photographs demonstrating residents facing out of the van when unloading. The facility no longer uses any contracted van services.