**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, review of the incident log, review of facility in-services records, review of a personnel file, review of the safety inspection bus checklist, review of witness statements and the facility ' s internal investigation, review of policies, review of the emergency medical transportation report, review of hospital records, review of the monthly maintenance logs, interview with the medical director, and resident and staff interviews, the facility failed to ensure a resident dependent on staff, was safely secured in the wheelchair with a seat belt during transportation in a facility bus when coming back from a physician visit. This resulted in Immediate Jeopardy when one resident (#91) was placed at potential risk for serious life-threatening harm and/or injuries, when Transport Driver #300 abruptly stopped the facility bus, causing Resident #91 to come out of her wheelchair and was propelled over two rows of seats and landing on floor, towards the front of the bus, sustaining a hematoma (a solid swelling area of clotted blood within the tissues) to the left side of her head. This affected one (#91) of three residents reviewed for use of assistive devices during transportation. The facility identified a total of 25 residents who utilize a wheelchair, the transport bus, and would be required to have the seat belt engaged. The facility census was 90. On 03/07/24 at 5:20 P.M., the Administrator #303 and Director of Nursing (DON) were informed that Immediate Jeopardy began on 01/31/24 at 3:00 P.M., when Resident #91 was done with her physician appointment and was to be transported back to the facility via the transportation bus, and Transport Driver #300 failed to safely secure Resident #91 and her wheelchair prior to leaving the physician ' s office. During the return trip to the facility, the driver made a sudden stop due to the car in front not using his turn signal. Resident #91 came out of her wheelchair; over two rows of seats and ended up on the floor towards the front of the bus. Resident #91 hit her head and had a visible bump on her head. Emergency (911) was called, the police arrived, and the resident was taken to the emergency room for evaluation and treatment. A Computed Tomography (CT) scan of the head revealed a left frontal scalp hematoma. The Immediate Jeopardy was removed on 02/01/24 when the facility implemented the following corrective actions: • On 01/31/24, at approximately 3:45 P.M., Transport Driver #300 had a sudden stop and Resident #91 fell during transportation. Transport Driver #300 notified Administrator #299 from the sister facility where the bus is stored, and where the transport drivers obtain the bus, for transports for both facilities. • On 01/31/24 at 3:49 P.M., Administrator #299 called 911 to seek emergency help. • On 01/31/24 at 3:53 P.M., Administrator #299 arrived on the scene of the accident, and the sheriff was present at this time. • On 01/31/24 at 3:59 P.M., 911 arrived, emergency treatment was provided, and Resident #91 was transported to the emergency room to be evaluated. • On 01/31/24 at 4:06 P.M., the facility was notified of the accident and Resident #91 ' s family was notified. • On 01/31/24 at 4:07 P.M., Transport Driver #300 was suspended, and the bus was inspected by Administrator #299 and the seatbelt was found to be in working order. • On 02/01/24 at 9:00 A.M., Administrator #299 completed re-education with all transport drivers. Education included bus safety with return demonstration competency. • On 02/03/24, Transport Driver #300 was provided termination paperwork effective 01/31/24. • On 03/07/24, the facility began daily safety inspections of the bus. If issues are identified with safety, the bus will not be driven until corrected. • On 03/07/24, in-servicing was completed by Registered Nurse (RN) Quality Assurance (QA) #304 of management staff on the policy and requirements of daily bus inspection. Management staff to complete a secondary audit of daily inspection to ensure safety protocols are followed prior to the resident leaving the facility to ensure resident safety. • On 03/07/24, daily audits Monday through Friday of the bus self-inspections will be performed by the Administrator or designee for four weeks and then randomly after for four months. • Beginning on 03/07/24, all results of the audits will be reviewed monthly by the Quality Assurance Performance Improvement (QAPI) committee and the Medical Director to ensure compliance. • On 03/11/24, review of two (#48 and #54) additional residents medical records who required assistive devices for transportation revealed no concerns. • On 03/12/24, between 2:32 P.M. to 2:40 P.M., interviews with Transport Driver #302 and #308, each stated they were in-serviced and educated on properly transporting residents and were followed on a live ride (return demonstration) by Transportation Coordinator # 306 about a month ago. Each stated one seat belt has been nonfunctional in bus #04. Transport Driver #301 stated the seatbelt was broken since he started two months ago. There are two spaces in the back of the bus to transport wheelchairs. The one is not operational and has a broken seatbelt. The broken one has had all of the seatbelts and hooks removed so that it cannot be accidentally used. Although the Immediate Jeopardy was removed on 02/01/24, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #91's medical record revealed an admission date of 10/25/19 and a readmission date of 01/24/24. Resident #91 had diagnoses including cardiac pacemaker, absence of right leg above the knee, heart failure, chronic kidney disease, Type II diabetes, anxiety, and hyperkalemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 was cognitively intact, required supervision with eating and needed partial assistance to moderate assistance with transferring. Further review of the MDS revealed the resident had impairment on one side of the lower extremity and used a wheelchair. Review of the care plan dated 01/24/24, revealed Resident #91 had a self-care deficit with Activities of Daily Living (ADL). Interventions included the assistance of two staff for transfers and uses a wheelchair. Review of the incident accident log dated 01/02/24 through 03/04/24 revealed no evidence of an accident on 01/31/24 with Resident #91. Review of witness statement dated 01/31/24 at 3:43 P.M., by Transport Driver #300, revealed the resident was sitting in her wheelchair and he made a sudden stop because the car in front did not use a turning signal. Resident #91 fell forward out of the chair. Transport Driver #300 stopped the bus and called 911. Review of the written statement dated 01/31/24 at 3:44 P.M., by Administrator #299, of a sister facility, revealed she was notified by Transport Driver #300 that he made an abrupt stop in the vehicle and Resident #91 slid out of her wheelchair. The bus was stopped on the side of the road. Administrator #299 arrived on the scene. Resident #91 had a bump on the left side of her head, and it was bleeding. The resident was alert and oriented. Emergency 911 arrived and transported Resident #91 to the hospital. Review of the statement dated 01/31/24 provided by Administrator #299 and Transportation Coordinator #306 revealed each inspected the seatbelts on 01/31/24 and they were found to be in working condition. Interview on 03/11/24 at 2:30 P.M., with Administrator #303 revealed the transport drivers are to be completing daily safety inspections of the bus. The facility was unable to provide any evidence of a daily bus inspection being completed on 01/31/24. The Administrator stated the facility was not retaining any written daily checklist. Review of the emergency medical transport notes dated 01/31/24 revealed 911 was called at 3:52 P.M., and arrived at the scene at 4:06 P.M. Resident #91 was located inside the wheelchair bus sitting on the floor. The Transport Driver (#300) of the bus, stated the resident was sitting in her wheelchair and fell out and hit her head. The resident denied any loss of consciousness but was on blood thinners; patients only complaint was pain near the hematoma. The resident remained stable during transport to the emergency room. Resident #91 was transported to the emergency room at 4:16 P.M. Review of Nurses Notes dated 01/31/24 at 4:03 P.M., revealed the facility received a call from Administrator #299 (from a sister facility) stating that Resident #91 was on her way back to the facility in the corporation owned bus, when the driver had to make a sudden stop. The resident came out of her wheelchair and had a bump on the left side of her head. The bus driver had called 911 and first responders were arriving. Nurses Notes dated 01/31/24 at 4:25 P.M., documented the resident was taken by ambulance to the emergency department. Review of the emergency room note written on 01/31/24 at 4:25 P.M. by Physician #298, noted Resident #91 was in transport bus when the driver hit the brakes, she went flying and hit her head. It is unclear if she had a seatbelt on or if the seatbelt had broken. Resident #91 had swelling to the head and a headache. Further review of the physician notes revealed the patient could be discharged . The patient had a fall and a head injury. There was soft tissue swelling to the frontal region. The patient was educated about developing a black eye on the left secondary to the hematoma. Review of the emergency room note written on 01/31/24 at 4:58 P.M. by Registered Nurse (RN) #297, documented Resident #91 told her the driver hit the brakes hard and that the strap broke on the transfer bus. Resident #91 states this caused her to fly to the front of the bus. Review of the emergency room notes revealed the final Computed Tomography (CT) scan result showed no evidence of acute intracranial trauma. However, there was a midline left frontal scalp hematoma. Review of the hospital summary dated 01/31/24 revealed Resident #91 had a closed head injury and contusion of the face. Review of the witness statement dated 02/01/24 by Maintenance Director #301, revealed he was never made aware of any seatbelts missing or broken on bus #04 and it was the driver ' s responsibility to inform their supervisor and maintenance of any safety concerns. Maintenance Director #301 stated he was informed of headlights not functioning, coolant leaks, doors not closing properly, and the lift not working. The above items had been addressed in routine maintenance, prior to the incident on 01/31/24. Review of the Quality Assurance (QA) Incident Summary for 01/31/24, revealed during the investigation the driver stated that he believed the seatbelt may not be working properly. Directly after the incident occurred while police were present, Administrator #299 inspected the bus and discovered the seat belt was in good working condition. The driver confirmed that a seatbelt issue had not been reported prior. Maintenance Director #301confirmed that the seatbelt was in good working order. The conclusion of the incident stated Transport Driver #300 did not secure Resident #91 properly using the four-point restraint for the wheelchair and the shoulder lap belt as required. Transport Driver #300 was terminated from his employment. Interview on 03/07/24 at 1:42 P.M. with Administrator #299 revealed she received a call stating Resident #91 was injured in an accident. She arrived at the scene and both Resident #91 and Transport Driver #300 were upset. Emergency 911 and the police arrived on the scene. Administrator #299 stated the police did not take a report. Transport Driver #300 stated there was an issue with the seatbelt and he confirmed he was rushing. Administrator #299 stated Transport Driver #300 did not confirm or deny Resident #91 was secured by a shoulder/lap belt. An inspection of the seatbelt was conducted and found the seatbelt was functional. Administrator #299 stated Transport Driver #300 was a good employee and had no prior disciplinary action. Transport Driver #300 was suspended during the investigation and then terminated. Interview on 03/07/23 at 2:06 P.M. with Resident #91 revealed she remembered the accident. Resident #91 stated she was sitting in her wheelchair at the back of the bus. She did not remember the driver securing the shoulder and lap belt. The driver made a sudden stop, and she flew out of her wheelchair halfway up the bus. She stated she hit her head on the seat. Resident #91 stated she was taken to the emergency room. During an interview on 03/08/24 at 12:47 P.M. with Transport Driver #300 he stated he was transporting Resident #91 back to the facility. Resident #91 was strapped in her wheelchair, and he made a slight tap/stop, and the resident came out of her wheelchair and ended up in the third row of seats. Further questioning on how the wheelchair was secured revealed there were four straps on the floor that were attached to secure the wheelchair. There was a shoulder/lap belt attached to the side of the bus that was pulled over to secure the resident. The shoulder/belt attached to a latch that was attached to a floor strap. Transport Driver #300 stated the shoulder/lap belt latch was not functioning and Resident #91was not secured with shoulder/lap belt. Transport Driver #300 stated he had an alternate way of securing the resident with the footrest. However, Resident # 91 ' s chair did not have any footrests attached to her chair. Transport Driver #300 stated if he drove carefully and slowly the resident would be safe. Transport Driver #300 stated he never reported the broken latch to Maintenance Director #301. Transport Driver #300 did not want the bus to be out of service because he needed employment. Interview on 03/11/24 at 10:22 A.M. with Director of Maintenance (DOM) #301 stated bus #04 passed its yearly inspection in May by the State of Ohio Bureau of Motor Vehicles and he performs monthly inspections that include checking seat belts. Transport Drivers are responsible for checking the bus daily for safety, which includes the functioning of seatbelts. DOM #301 stated he checked the bus upon return from the accident and found the shoulder/lap belt to be functioning. Observation on 03/11/23 at 2:15 P.M. with Transport Driver #302 and Administrator #303 revealed the bus had three rows of seats with two seats on each side of the bus. There was a space in the back of the bus to secure two residents with wheelchairs. There were two shoulder/lap belts attached to the side of the bus. One for each wheelchair. The shoulder/lap belt on the passenger side was not functioning for a while. Each wheelchair has four attachments on the floor. The facility took out the four floor attachments to the floor on the broken seatbelt side. This was to ensure transporters would only be able to secure wheelchairs on the functioning seatbelt side. Interview with Transport Driver #302 stated the latch was broken and only one resident with a wheelchair is transported at a time. Review of Transport Driver #300 ' s personnel file revealed he was hired on 09/05/23 and received a five-day training in transporting residents. The transporter job description signed on 08/24/23 stated an essential job function is to transport residents to and from appointments in a manner conducive to resident safety. Review of the termination form dated 02/03/24, revealed a termination date effective 01/31/24. The reason listed stated a violation of company policy. Interview on 03/11/24 at 12:28 P.M. with Administrator #303 confirmed Transport Driver #300 was terminated for unsatisfactory work performance and violation of company policy. She was unable to provide additional information regarding Transport Driver #300. Interview on 03/11/24 at 1:31 P.M. with the Medical Director revealed he was notified of the incident with Resident #91and was involved in the Quality Assurance meeting and determined to avoid any future occurrence, he instructed to provide further education on transporting residents. Review of the monthly maintenance logs dated from 03/31/23 through 02/29/24 revealed monthly maintenance checks were completed. There was no documentation for a broken seatbelt on the bus. Review of the policy titled Bus/Maintenance Inspections, revised on 02/01/24, revealed transportation vehicles to be inspected by the Maintenance Director monthly. Any issues or concerns with inspection will be reported to the administration immediately. Review of the policy titled Securing Resident for Bus/Bus Transportation, revised on 02/01/24, revealed resident to be secured by the driver in wheelchair using bus system (a four-point tie-down system.) Seatbelt to be applied once the wheelchair is secured. Any issues or concerns with securing residents should be reported immediately and administration to be notified. This deficiency represents noncompliance investigated under Master Complaint Number OH00151205 and Complaint Number OH00151678.