**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, document review, facility policy review, and review of manufacturer's information for the facility's wheelchair securement system, the facility failed to properly secure Resident (R)225 in the facility's transportation van while transporting the resident back to the facility following an appointment. On 10/14/2022, at approximately 2:30 PM, the Van Driver placed R225 in the facility van, securing the wheelchair in the back, locking the wheelchair brakes, and placing the lap belt on the resident, but did not secure the front of the wheelchair. Upon leaving the parking lot, the van stopped at a red light that was on an incline, and when the van started to move, the resident's wheelchair flipped backwards, causing a skin tear to the resident's right hand, abrasion to the forearm, and a knot to the back of the resident's head. R225 was then provided first aid by the Minimum Data Set (MDS) Nurse, who was also on the van for the transport, and then the wheelchair was secured in the van for transport back to the facility. On 04/19/2023 at 6:08 PM, the interim Administrator was presented with an Immediate Jeopardy (IJ) template that indicated IJ existed at F689 with a start date of 10/14/2022 and an end date of 10/17/2022. Implementation of the facility's corrective action plan was verified through observation, staff interviews, and record reviews. Observation and interviews with the Van Driver and MDS Nurse revealed they had received training on how to properly secure residents in the facility van. Additional review revealed the facility failed to complete a thorough investigation of falls to determine the root cause and develop interventions for 1 (R70) of 7 residents sampled for accidents. Furthermore, the facility failed to ensure the environment remained free of accident hazards for 1 (R19) of 4 residents reviewed for medication self-administration. Specifically, staff allowed R19, who was cognitively impaired and assessed to be unable to self-administer medications, to store medication at the bedside. Findings include: 1. A review of the facility's policy titled, Transportation Guidelines, revised 01/25/2016, revealed guidance on how to provide safe transportation for patients/residents. The section for Requirements for Transporting included the following: 1. The partner shall have completed all training outlines [sic] in the Van Transportation Certification Program. A review of the facility's policy titled, Driver Authorizations, issued November 2012, revealed, Healthcare Center will maintain a system for making certain that all partners who operate or occupy a motor vehicle for transportation have been authorized by the Administrator and have met required training and qualifications. The policy also indicated, The Administrator is responsible for monitoring the compliance to this policy. A review of a facility policy titled, Wheelchair Transports, issued November 2012, revealed, The transportation partners are responsible for the implementation of this policy. The policy directed staff on the steps to take for Safe use of Wheelchairs, including the following instructions regarding strapping the wheelchair down in the transportation van: When securing a wheelchair, attach the four tie down straps to the securement points provided on the wheelchair. Tighten the straps to remove all slack. A review of a facility policy titled, Competency Requirements for Van Drivers, issued November 2012, revealed, Healthcare Centers recognize the importance of having competent partners that have received training and education related to providing transportation services. Responsible Parties: The Administrator is responsible for monitoring compliance to this policy. Education Requirements: Wheelchairs: Transportation Aide has completed the wheelchair training by the approved trainer. The policy indicated this training would be completed upon hire and annually. A review of the undated manufacturer's information from the facility's wheelchair securement system revealed the product was designed to make transportation safer for passengers with special needs. The manufacturer's information also indicated, As transportation professionals, you are responsible for the safety and welfare of your passengers. That's why it's extremely important to learn the correct way to secure passengers and their wheelchairs and comply with the regulations that apply to you. Section 4: Securing the Wheelchair revealed, Correctly securing a wheelchair is extremely important for the safety and comfort of the passenger as well as your own peace of mind. Injury or death may result from improper securement. A review of R225's Resident Face Sheet revealed the resident was admitted to the facility with diagnoses including vitamin D deficiency, muscle weakness, and difficulty walking. A review of R225's admission MDS, dated [DATE], revealed R225 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. The MDS also indicated R225 used a wheelchair for mobility. A review of R225's Resident Progress Notes, dated 10/14/2022, revealed that during the transport back to the facility from their dialysis appointment, R225's wheelchair flipped backwards, and R225 sustained a golf-ball size area to the back of the head, an abrasion to the right elbow, and a skin tear on the left hand. During an interview on 04/19/2023 at 8:42 AM with the Van Driver, he stated that prior to 10/14/2022 he had only driven the facility's van four or five times and had always had a certified nursing assistant (CNA) present with him to secure the residents in the van. The Van Driver said on 10/14/2022 he picked up R225 from an appointment, and when he was securing R225's wheelchair into the van, the resident asked him not to secure the front of the wheelchair. He said once they were in route to the facility, they had to stop at a red light, which was on an incline, and when he put the van into motion, the resident's wheelchair flipped backwards. He said he then pulled the van over and the MDS Nurse, who was also present on the van, checked on the resident and provided first aid. The Van Driver said they then set up the wheelchair and he fully secured the resident's wheelchair in the van and transported the resident back to the facility. He said the reason R225's wheelchair flipped backwards was because he failed to fully secure the resident's wheelchair when he did not secure the front of the wheelchair. He said that he did not recall ever being checked off on how to transport or secure residents prior to the incident on 10/14/2022. During an interview on 04/19/2023 at 9:45 AM with the MDS Nurse, she stated 10/14/2022 was the first time she ever transported a resident. She indicated the administrator at that time asked her to go along for the transport because they did not have any other staff available to go with the Van Driver. The MDS Nurse said she had not received any training on transporting residents prior to this incident, and she was just along for the ride, and did not provide any assistance to the Van Driver in securing R225's wheelchair. She said she relied on the Van Driver to know how to properly secure the resident. The MDS Nurse said after R225 finished their dialysis appointment, the Van Driver loaded the resident and wheelchair in the facility van and secured the back wheels. She said she overheard R225 tell the driver not to lock down the front of the wheelchair. She said she saw the driver secure the wheelchair, but he did not secure the front of the wheelchair. She said that on the drive back to the facility, they stopped at a red light that was on an incline, and when the Van Driver began moving again after the light changed, the resident's wheelchair flipped backwards. She said they immediately pulled the van over, and she assessed the resident. She said the resident had a skin tear on the right hand, an abrasion to the elbow, and a small knot on the back of the head. She provided first aid to the resident, then they raised the wheelchair back up, and the Van Driver fully secured the wheelchair and they returned to the facility, where she gave a report to the nurse. On 04/19/2023 at 3:15 PM, the Van Driver demonstrated how to secure a wheelchair in the facility van. He said that on 10/14/2022, he secured the back of the wheelchair, locked the brakes, and placed the long seat belt on the resident, but did not secure the front of the wheelchair because the resident requested for him not to. During an interview on 04/21/2023 at 11:52 AM, the MDS Nurse stated she should have reminded the Van Driver and the resident of the importance of properly securing the wheelchair, and she should have reached out to her supervisor when she realized the resident had not been properly secured in the van. During an interview on 04/21/2023 at 12:39 PM, the interim Director of Health Services (DHS) stated she thought they should have provided some more training to the staff regarding transporting residents. She said they did not use the van for transports at this time. During an interview on 04/19/2023 at 11:38 AM with the Administrator, she stated that since the incident on 10/14/2022, they had used an outside transportation company for all transporting needs of the residents. The facility van had not been used since the incident on 10/14/2022. The facility's undated Plan of Correction developed following the 10/14/2022 incident included the following corrective actions: 1. [Van Driver] is not to transport any longer. 2. All transport personnel are not to drive van until full completion of required education/competency and DMV [Department of Motor Vehicle] checks are completed. 3. Scenario education to be provide when a resident refuses safety devices-Van is NOT to transport under any circumstances. 4. Scenario education on what to do when an event occurs; - Immediately stop the van in a safe location- - Call Administrator and 911 - Have EMS [emergency medical services] to evaluate-if resident refuses to seek medical attention have resident transported back to facility by EMS. - Immediate inspection and re-enactment need to occur to determine root cause related to any accidents/incidents. 2. Review of the facility's policy titled, Occurrences, revised 11/29/2022, revealed, Investigation and Follow-up: 1. Occurrence investigation and follow-up is a joint responsibility within the healthcare center. 2. Communication between all parties is essential for identifying the events and circumstances that resulted in the occurrence and for identifying interventions that limit the risk of occurrence being repeated. The policy further indicated, 6. Director of Health Services will be responsible to review each occurrence for thorough investigation, documenting the investigation on the patient/resident care software occurrence report and appropriate care plan interventions are put in place to decrease risk for repeated occurrences. 7. The Administrator or designee will complete the supervisor investigation on all occurrences. A review of R70's Resident Face Sheet revealed the facility admitted the resident with diagnoses that included difficulty in walking, dizziness and giddiness, repeated falls, and muscle weakness. A review of R70's admission MDS, dated [DATE], revealed R70 had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. R70 had no history of falls on admission. R70 required limited assistance of one person for transfers. R70 was unsteady during transitions and walking and was only able to stabilize with staff assistance. A review of R70's comprehensive Care Plan, revealed a care plan addressing Falls, dated 11/14/2022. The falls care plan indicated R70 was at risk for falling R/T [related to] requiring assistance with ADLs [activities of daily living], incontinence of bowel and bladder, seizure disorder. A review of a Progress Note, dated 11/11/2022 at 7:17 PM, indicated R70 slid to the floor from the bed during an attempt to toilet without assistance. A review of a Progress Note, dated 11/21/2022 at 5:20 PM, revealed R70 was observed sitting on the bathroom floor at 4:15 PM. R70 reported to staff they were attempting to self-toilet and slipped and fell. A review of a Progress Note, dated 12/03/2022 at 6:49 PM, indicated the CNA assigned to R70 notified staff the resident slid out of their wheelchair while attempting to self-transfer. A review of a Progress Note, dated 12/14/2022 at 8:16 AM, indicated R70 had gotten out of the bed, walked to the bathroom without assistance, and fell. A review of a Progress Note, dated 01/18/2023 at 2:25 PM, revealed R70 was observed sitting on the floor beside the bed. R70 reported to staff they were trying to reach an item on top of their bedside table and slid to the floor. R70 verbalized they landed on their buttocks and denied hitting their head. On 04/18/2023 at 12:50 PM, the Administrator said they had provided all investigations or incident reports for R70 for November 2022 through the current date. She confirmed there were no fall investigations for R70's falls on 11/11/2022, 11/21/2022, 12/03/2022, 12/14/2022, and 01/18/2023. During an interview on 04/18/2023 at 2:18 PM with the Administrator, she stated she expected the staff to start an investigation when a resident had a fall. During an interview on 04/19/2023 at 2:03 PM with Licensed Practical Nurse (LPN)1, she stated R70 liked to be independent and would try to go to the bathroom without assistance. She said they tried to re-direct the resident and remind the resident to ask for assistance. She said for falls, a root cause should be identified, and interventions would be put in place to keep the resident safe. During an interview on 04/21/2023 at 12:39 PM with the interim DHS, she stated she needed to know immediately if a resident had a fall so she could conduct an investigation. During an interview on 04/21/2023 at 1:07 PM with the Area [NAME] President (VP), he stated he expected the staff to follow the facility's fall policy, conduct investigations, and implement interventions to keep the residents safe. 3. A review of a facility policy titled, Self-Administration of Medications by Patients/Residents, revised on 01/24/2020, revealed, Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center. A review of the Resident Face Sheet revealed the facility had admitted R19 with Parkinson's disease, muscle weakness, dementia, generalized anxiety, intercostal pain, and collapsed vertebrae. A review of the quarterly MDS, dated [DATE], indicated R19 had a BIMS score of 3 out of 15, which indicated the resident had severely impaired cognition. The MDS revealed the resident had impaired vision and was only able to see large print. R19 required extensive assistance of staff for bed mobility, dressing, and personal hygiene and required supervision for eating. Further review of the MDS revealed a staff assessment for pain was not conducted for the resident. The resident's care plan, dated 02/28/2023, indicated R19 had self-care deficits related to poor cognition and the resident's physical status. The facility developed an intervention that directed staff to observe the resident for signs and symptoms of discomfort during care. A review of R19's Self-Administration of Medication assessment, dated 11/17/2022, indicated based on the assessment, it was not appropriate for the resident to self-administer medications; subsequently, the resident would not be storing medications. Observations made on 04/17/2023 at 10:05 AM, 04/18/2023 at 1:57 PM, and 04/19/2023 at 8:30 AM revealed a tube of generic arthritis pain gel was seen in the resident's room. A review of R19's Physician Order Report revealed the resident had an order for a Lidocaine self-adhesive patch applied to the skin for pain and for Voltaren arthritis pain gel to be applied twice a day for pain. There was no documented evidence the resident had an order to self-administer medications, to keep medications at the bedside, or for R19 to have a generic arthritis pain gel. CNA17 was interviewed on 04/19/2023 at 9:10 AM and stated if she saw medication at a resident's bedside, she would remove the medication and give the medication to the nurse. The CNA stated she would be scared a wandering resident may get the medication. She stated there was one resident who wandered on the unit where R19 resided who had been seen going in and out of other residents' rooms. Registered Nurse (RN)19 was interviewed on 04/20/2023 at 1:45 PM. The nurse was aware of the pain cream at R19's bedside. RN19 stated a family member gave the resident the pain cream. RN19 stated she had tried to educate the family, but the family continued to bring the medication to the resident. The DHS was interviewed on 04/21/2023 at 11:57 AM. The DHS stated a resident with a BIMS score of 3, such as R19, would not be competent to self-administer medications. She stated she expected staff to immediately remove any over-the-counter medications from the room. The DHS further stated if the family continued to bring medication and leave it at the resident's bedside, she expected the nurse to educate the family. If the family continued to bring in medication, she expected the nurse to report the situation to the DHS. According to the DHS, she had received no reports regarding the over-the-counter medication in R19's room.