**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that two (2) of 84 residents were free from neglect when it failed to maintain and provide safe transportation for the resident in the facility van. Resident #69 experienced a fall that resulted in actual physical harm when they suffered a fracture to both legs. In addition Resident #84 sustained several falls where the care plans were not implemented or revised. She sustained on final fall on 06/10/23. Review of Physicians/Medical Examiners Certification of Death for Resident #84 dated 6/29/23, evidenced the cause of death as complications of blunt force injuries. The description of how injury occurred was a fall striking head on a doorway while ambulating down hallway. The failure to put interventions in place for Resident #84 after her numerous falls resulted in actual harm. This was true for two (2) of three (3) residents reviewed for falls. Actual harm was only suffered by Resident #69. Resident identifiers: #69 and #84. Facility census: 84. Findings included: a) Resident #69 A record review showed a nurses note dated 06/19/23 at 7:45 AM. indicated Resident #69 was out of the building via facility van for an appointment in [name of town] for a pacemaker check. A review of an incident report dated 06/19/23 showed a fall from a wheelchair during transport for Resident #69. The only witness to the fall was the facility van driver, Transport Certified Nurse Aide (TCNA) #99. Emergency Medical Services (EMS) was called on 06/19/23 at 8:10 AM and used on 06/19/23 at 8:45 AM. Resident #69 was sent to local hospital at 8:45 AM. A review of the incident report revealed Resident #69's statement. In this statement Resident #69 indicated that when the van pulled over it was bumpy, and it shook her, and she fell out of the wheelchair. Position of Resident #69 when found was fell forward onto stomach from wheelchair. The conclusion statement of the incident report showed on 06/19/23 Resident #69 was being transported in facility van when the van driver needed to pull off to check resident's oxygen. When the driver pulled over, Resident #69's first name went forward in her wheelchair and fell onto the floor of the van. EMS was notified and when arrived at the scene Resident #69 complained of pain in her leg. The Resident was then transported to [local ER name] who notified the facility that Resident #69 sustained a left femur fracture and a right tibia/fibula fracture. Resident #69 was then transferred to [trauma facility hospital name] and then readmitted back to nursing home facility on 06/21/23. The van was immediately evaluated by maintenance, Administrator, and Director of Nursing (DON) for working order. The van was tagged out of use until evaluated by the Divisional Director of Facilities Management and released for use on 06/28/23. A review of the local Emergency Department's (ED) report where Resident #69 was initially transported after the fall stated the patient was a paraplegic who was wheelchair bound. She was being transported to an orthopedic appointment and the transport driver stated the lap belt in the van was inadequate and that while driving the patient fell forward onto the floor causing pain in bilateral lower extremities. The ED report showed findings of a displace fracture of the medial condyle of the left femur, initial encounter for closed fracture, and a closed fracture of the right proximal tibia and proximal end of right fibula. Resident #69 was transferred from the local ED to a Trauma center at 2:40 PM for orthopedic surgery evaluation. Review of the discharge summary from the trauma center indicated the tentative plan for non-operative treatment of right proximal tib/fib fracture and left distal femur fracture. This plan included the following: Bilateral hinged knee braces were placed flexed to accommodate knee flexion contractures. Orders to have repeat x-rays on 06/21/23, and if stable continue no-operative treatment. Follow up appointment with orthopedics in 2 weeks. A nurses note dated 06/19/23 at 7:54 PM stated the patient was out of the facility. Per Dayshift, Resident #69 was being transported to doctor appointment in facility van and fell out of wheelchair and complained of leg pain. The patient was taken to the local ER for evaluation and then was transferred to [other hospital name] for further evaluation. This nurse has contacted [other hospital name] to check on status of patient and per ER nurse, the resident was admitted for a fracture to the tibia/fibula and femur. Nurses Note dated 06/21/23 at 9:19 PM stated Resident #69 arrived via ambulance back to facility from previous fall on 6/19/23. Resident came back with a right proximal tibia/fibula fracture and left distal femur fracture. Resident was placed in bilateral hinged knee braces flexed to accommodate knee flexion contractures. Recommendation to follow up w/ortho in 2 weeks. Skin issues were as follows: bilateral hand/arm with various discolorations, lower abdomen with slightly yellow discoloration, slightly red under abdominal fold, discolorations observed on right side of back (measuring 7 x 5 cm (centimeters) and 4.4 x 4 cm) and left side of back (measuring 2.5 x 2.2 cm & 2 x 0.6 cm). Record review showed an order dated 06/22/23 for Hinged Knee braces to bilateral extremities. Unbuckle and reposition braces check circulation and skin every shift for prevention of skin breakdown. Review of the admission evaluation, effective date 06/21/23 showed discoloration to the skin on the abdomen, bruise on right shoulder measuring 7 cm length by 5 cm width, bruise on left upper back measuring 2.5 cm length by 2.2 cm width, a second bruise on left upper back measuring 2 cm length by .6 cm width, and a bruise on right upper back measuring 4.4 cm length by 4 cm width. Record review showed a reportable completed on 06/19/23 for a fall incident that occurred to Resident #69 during facility van transport to a doctor's appointment on 06/19/23. Witness statement from the van driver, Transportation/Certified Nurse Aide (TCNA) #99 stated, When I arrived at work, I was informed I would be transporting [resident #69's first initial, last name] to [location of appointment]. I had a transport scheduled for another resident but was told to take [resident #69's first initial, last name]. Around 8:15 I received a call from the unit manager asking about oxygen for [resident #69's first initial, last name] and that they may have to reschedule. I told unit manage I would pull over and check oxygen tank and call her back. When I found a wide spot on side of road I pulled over when I put van in park [resident #69's first initial, last name] fell forward into floor of the van. I had her wheelchair locked, restraints on each wheel, and seat belt across her thighs. I called unit manager then I called 911 for help. Witness statement signed by TCNA #99, dated 06/19/23. Resident #69's witness statement from the reportable completed on 06/19/23 stated (typed as written), I was on way to appointment. Going down road the driver needed to make phone call. Pulled the van over. Driver stopped quickly. Was slowing down. Road was rough. When she stopped I went forward. I was flat on stomach unable to move. I had no pain at this time. Lap belt was to little and I did not have it on me. As far as I know the wheels strapped in. The further I went to hospital for evaluation the more pain I started to feel. I have never had any trouble in the van previously I have had the lap belt on to (two) other visits, but I guess I outgrew it. Witness statement was signed by Resident #69, dated 06/22/23. On 08/28/23 at 1:28 PM, during an interview with TCNA #99 the TCNA stated, They changed my transport to take [Resident #69's name]. They [the facility] had a question about O2 (oxygen). When I got to a turnaround spot, I pulled over. When I put the van in park heard a thud she [resident #69] had fell in floor. The resident moaned a little bit. I had 911 to get her out and she [Resident #69] stated she [Resident #69] was fine and but I said she [Resident #69] should go get checked out. Her [Resident #69] legs was hurting a little bit. She [Resident #69] went to [local hospital name] ER. The Admins' here wanted me to come back to get statement. TCNA #99 said the belt used was what she always used. She [Resident #69] is kind of top heavy, belt was across her lap. Wheelchair was secured down with the rachet straps and was locked and in place. At the ER they transferred her [resident #69] to [hospital name] via ambulance. Van is still used but did not use it until it was checked by corporate and now has a belt that goes across upper body. During an interview on 08/28/23 at 2:20 PM, Resident #69 stated, They [facility staff] told me I had an appointment to go to in [healthcare center's location]. She [Transportation/Certified Nurse Aide (TCNA) #99] got a phone call from here [the facility] and had to pull off the side of the road. She [TCNA #99] didn't slow down much, or at least I didn't think so. All of a sudden she came to a stop, next thing I know I was in the floor, face down with my head up under the van seat. Resident #69 further explained that some firemen came and got her up, then started having pain all over and agreed to the emergency room. Resident #69 stated, I hit my head on the seat, I had a scuff on the side of head, and I was bruised awful on my back and arms. They [local ER] x-rayed me and I had 2 broke legs. I did not have my seat belt on, but the wheelchair was fastened to the floor with straps, so it did move, but I did. The Resident then tearfully stated, You know what the sad is, I didn't even have an appointment that day. So two (2) broke legs for nothing Resident #69 also explained she was paraplegic, and had no way of bracing her fall when the van came to a sudden stop. Resident #69 explained that she takes her own red wheelchair on outing and appointments because it has its own seat belt for her safety. Resident #69 was in her red wheelchair the day of the accident; however, the Resident stated TCNA #99 did not hook her seatbelt because she could not get it to reach around her. It was later discovered by the resident's son that the belt had become tangled, and he was able to free the belt by yanking it loose. Resident #69 concluded by stating TCNA #99 had told her uppers [Administrative staff] several times it was too dangerous to transport her that way, but they never listened. Resident #69 was deemed to have capacity on 03/09/23 by the facility's physician. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/30/23 showed a Brief Interview for Mental Status (BIMS)'s score of 14. A score of 13 to 15 suggests the patient is cognitively intact, with 15 being highest score achievable. During a phone interview at 7:05 PM on 08/28/23, Resident #69's son/Medical Power of Attorney (MPOA) stated they did not put a proper seat belt on her. The seat belt on the wheelchair was wrapped up in such a way it couldn't be hooked. They had no shoulder harness to put on her, just a strap they pout across her knees. The wheelchair was fastened to the floor, so it didn't move. They were going to send the van out to get it fixed. It set there for 2 or 3 weeks. MPOA stated Resident #69 ended up under the back seat, hit her head, had a bruise on her cheek, and was bruised up bad on her arms and back. MPOA further stated the accident was completely preventable, Resident #69 didn't even have an appointment that day. MPOA stated that the driver had stopped the van to check her oxygen and turn around to come back to facility. Now the Resident has 2 broke legs and that just adds more risks and limitations to her. At [trauma center's name she was transferred to from Local ER] couldn't do any surgery due to Residents COPD and heart, the facility stated to MPOA Resident would never come out of anesthesia. Record review showed the following diagnoses paraplegia onset 12/13/19, chronic obstructive pulmonary disease onset 12/17/19, dependence on supplemental oxygen onset 12/22/21, displaced fracture of medial condyle of left femur onset 06/19/23, fracture of upper end of right tibia onset 06/19/23, fracture of lower and upper end of fibula onset 06/19/23, unspecified fall 06/19/23. On 08/29/23 at 9:33 AM, Unit Supervisor Registered Nurse (RN) #50 stated she was the one that called TCNA #99 around 8:20 AM during Resident 69's transport on 06/19/23. RN #50 stated she needed TCNA to check Resident #69's oxygen (O2). The Resident was ordered to be administered supplemental oxygen at 2 liters nasal cannula continuous. RN #50 verified the Resident did not have any oxygen on the van with her to use, it was not sent on the transport. Once TCNA # 99 found out the O2 was not in place, she was to turn around and come back to the facility. RN #50 also verified that around the same time it was discovered the resident's appointment was not even scheduled for that day (06/19/23). RN #50 stated the order for the cardiology appointment to have the pacemaker checked was entered for 06/19/23 and should have been for 10/19/23. Record review showed an order for Oxygen @ 2 LPM per nasal cannula every day and night shift for COPD. Start date 02/20/23. On 08/29/23 at 5:20 PM the DON verified Resident #69 was to have supplemental oxygen on at all times, including during transport. During an interview on 08/29/23 at 3:15 PM, Maintenance Supervisor (MS) stated after the accident the facility ordered another harness type seat belt that goes across the shoulder. The transport van was parked for a couple of weeks until the new seat belts were installed. The day of the incident, the resident was in her wheelchair in the back of the van behind the seats with the four-point restraints attached to the wheelchair holding it in place on the floor. The lap belt was placed across the resident's legs. It was noted the resident's wheelchair used during transport did not have full arms. On 08/30/23 at 8:42 AM, a demonstration was provided by TCNA #99 of how Resident #69 was positioned in the transport van in the wheelchair on 06/19/23. The surveyor set in a wheelchair that was positioned approximately 3 feet from back row of van seats. This is where TCNA #99 indicated the wheelchair was placed in the van for the transport on 06/19/23. TCNA #99 locked the wheels of the chair and attached the four-point restraint straps from the wheelchair to the floor. At that time, the wheelchair was immobile. TCNA #99 then placed what she called the lap belt across surveyor's legs approximately 5 inches up from the knees. The lap belt was not threaded through the wheelchair arms, just laying across the knees. TCNA #99 stated she did not thread the lap belt through Resident #69's wheelchair on 06/19/23, because the Resident's red wheelchair did not have arms that fully connected to the wheelchair base. TCNA #99 was asked if she used the shoulder harness seatbelts that were attached to the inner vehicle structure wall on 06/19/23? TCNA #99 replied, No, those were not in here [in the van] at that time. They were added after the accident. The Maintenance Supervisor (MS) and the Administrator were both present for the demonstration and verified the placement of the lap belt on surveyor's legs to be approximately 5 inches above the knees laying across thighs. MS agreed the placement of the lap belt would not have stopped anyone from falling forward out of the wheelchair. The MS stated, If the Resident was bruised on her back it was probably from the braces under the van seat she slid up under. Review of an email provided by the Maintenance Supervisor dated 07/11/23 from the Divisional Director of Facilities Management (DFM) showed the DFM had reached out to a supply company on 07/10/23 to check the status of the new combination seat belt order. A written statement from the MS stated the facility van was taken out of service on 06/19/23 until the DFM could come down on 06/28/23 and inspect it. After this inspection, a new shoulder belt attachment was ordered, and the lap belt was taken out of service. The statement further indicated the facility now only uses the shoulder harness to secure the resident in the wheelchair for transport, along with the four-point attachment on the chair. During an interview on 08/30/23 at 9:10 AM, the Administrator stated, Accidents happen, we are going to use this [Resident #69's fall on 06/19/23] to build on and improve our facility van transportation safety measures. b) Resident #84 Document Review: Review of Physicians/Medical Examiners Certification of Death for Resident #84 dated 6/29/23, evidenced the cause of death as complications of blunt force injuries. The description of how injury occurred was a fall striking head on a doorway while ambulating down hallway. Review of the most recent care plan received from the facility, page eight (8) of twenty-three (23) evidenced interventions initiated on 3/11/23 and revised on 6/21/23. 1.) Residents require supervision assistance with ambulation. 2.) Residents require supervision assistance with locomotion. Review of monthly incident logs from March 1, 2023, to July 31, 2023 reveal evidence of one hundred-sixty three (163) falls within the facility. Resident #84 suffered seven (7) falls within this time frame. Resident #84 falls. 03/14/23 fall, reported no injury. 03/17/23 fall, reported no injury. 03/30/23 fall, reported no injury. 04/04/23 fall, reported no injury. 04/09/23 fall, reported no injury. 04/23/23 fall, reported no injury. 06/10/23 fall, reported head trauma. Review of meeting minutes for Quality Assurance Performance Indicators (QAPI) dated 08/23/23 indicate reason for the meeting was to discuss falls within the facility. Plans initiated were to continue rounds, develop a high-risk resident fall list, increase monthly medication reviews, fall interventions and on-going education of staff. The Director of Nursing (DON) would be notified of each fall to assist in determining the root cause. Review of Fall Risk Observation Tool and Assessment Tool showed discrepancies in the overall level of assistance needed. Fall Risk Observation-assessment dated [DATE] indicated that no assistance was required for transfers and Resident #84 is able to ambulate without assistance. Fall Risk Observation-assessment dated [DATE] indicated minimal assistance with gait belt; may use walker for transfers. Resident #84's walking is noted as impaired with difficulty rising from chair, head down when walking and grasps furniture. Balance is referenced as poor balance when standing, balance problem when walking and instability while turning. Fall Risk Observation-assessment dated [DATE] indicates that no assistance is required for transfers and Resident #84 is able to ambulate without assistance. Fall Risk Observation-assessment dated [DATE] indicated minimal assistance with gait belt; may use walker for transfers. Balance problem while standing. Gait: weak walking and short, shuffled steps, lightly touching furniture for support. Fall Risk Observation-assessment dated [DATE] indicated that no assistance was required for transfers and Resident #84 is able to ambulate without assistance. Gait: weak walking and short, shuffled steps, lightly touching furniture for support. Balance: Able to stand/walk, maintain body alignment. Fall Risk Observation-assessment dated [DATE] indicated that no assistance was required for transfers and Resident #84 is able to ambulate without assistance. Gait: weak walking and short, shuffled steps, lightly touching furniture for support. Balance: balance problem while walking. Fall Risk Observation-assessment dated [DATE] indicated that no assistance was required for transfers and resident #84 can ambulate without assistance. Gait: weak walking and short, shuffled steps, lightly touching furniture for support. Balance: able to stand and walk. Post Fall Risk Observation-assessment dated [DATE] indicates that no assistance is required for transfers and Resident #84 is able to ambulate without assistance. Gait: Normal walking/striding without hesitation. Balance: able to stand and walk. Review of [NAME] Virginia University Hospitals Discharge summary dated [DATE], reflected that Resident #84 suffered from paralysis to nondominant side due to old stroke and osteoarthritis of both knees. Injuries from the fall include contusion and laceration to the chin, small skin tear on right hand and mandible fracture. Review of [NAME] Report dated 06/16/23 reflected the following: Transfer and toileting- transfer status independent, requires limited assistance with dressing, requires supervision assistance with ambulation, supervision assistance with bed mobility, supervision assistance with locomotion. Review indicates discrepancies in status and level of assistance needed. Staff interviews: An interview was conducted on 8/29/23 at 10:42 AM with Certified Nursing Assistant (CNA) #32. During this interview CNA #32 was asked about the incident that took place on 6/10/23 involving Resident #84. CNA #32 stated they were not working on that hall but were present during the incident. CNA #32 stated they were feeding another resident, but the door was open, and they could see and hear down the hallway. It was explained that CNA #32 could hear footsteps in the hall, like someone was running. I didn't know she could run. CNA #32 stated that by the time she saw Resident #84 and tried to get up out of my chair to check on her, the resident had already fallen to the floor. I went to the resident, and she was able to tell me, well it was a broken sentence, but she stated she hit her head. CNA #32 stated that by the time, LPN #23 and CNA # 29 were there with Resident #84. When asked about Resident #84 care plan, CNA #75 acknowledged staff were to keep an eye on Resident #84 because if she got tired, we were to get her the wheelchair. An interview was conducted on 8/29/23 at 10:00 AM with CNA #75. CNA #75 was asked about the incident that took place on 6/10/23 with Resident #84. It was stated that Resident #84 was always walking around and up and down the hall. It was stated that Resident # 84 was frequently walking around, and she tried to walk too fast. CNA #75 said, I didn't know where she was going all the time. Resident #84 was able to walk independently. She would never allow us to get her a walker or help her. CNA #75 stated they were feeding another resident when they heard a loud noise like someone running down the hall. CNA #75 said, When I went to the door, I saw Resident #84 in the floor. An interview was conducted on 8/30/23 at 8:45 AM with Social Worker (SW) #51. SW #51 was asked about the development and implementation of Resident #84 care plan and interventions. SW#51 stated that they did not write the interventions for ambulation and locomotion that are on the care plan. SW#51 could not offer an explanation or understanding of the interventions that stated: Resident requires supervision assistance with ambulation and locomotion. SW#51 stated they were not present when Resident #84 fell. SW#51 did state that they had seen the resident walking frequently independently. SW#51 stated the resident was able to walk and go where they wanted. It was explained that there had been conversations with the resident about using a cane or walker for safety, but the resident had refused all suggestions. An interview was conducted on 8/30/23 at 8:22 AM with the Infection Control Preventionist/Registered Nurse (ICP/RN) #13. CP/RN #13 was asked about the incident involving resident #84 on 6/10/23. CP/RN #13 stated that they were on the floor doing supervision that day. It was reported that CP/RN #13 did see resident #84 walking around in the hall. When asked if Resident #84 was ambulating independently, CP/RN #13 stated Yes. CP/RN#13 stated they were not aware if anyone was monitoring or watching the resident. CP/RN #13 stated they heard a loud bang noise. I went to see, and the resident was on the floor. Resident was moaning. Resident was assessed, the doctor was called, and resident was sent out to the hospital. When asked about how changes in treatment and interventions are relayed to various staff that might be working with residents, CP/RN #13 stated that any changes in inventions or care is updated in the Kardec system and staff review changes there. There are also morning meetings where changes and resident statuses are updated. CP/RN#13 was asked about the interventions on Resident #84's care plan and what the interventions meant. CP/RN#13 stated the intervention stating: requires supervision assistance with ambulation and locomotion means 'help from staff'. That the resident is supposed to have someone with them when they are walking. So, is this something that staff should be following if it was the intervention on 6/10/23? Yes, if it was active on that date, they should have been following that intervention. An interview was conducted on 8/30/23 at 9:33 AM with the Executive Director (ED) #108. The ED #108 concurred that there had been one-hundred and sixty-three (163) falls within the facility from March 1, 23 until July 31, 23. The ED #108 concurred that the medical examiners findings for cause of death stated immediate cause resulting in death was stated on the Death Certificate as: Complications of blunt force injuries, injuries occurred: fell striking head on doorway while ambulating down hallway. ED#108 refused to comment on interventions in place at the time of incident indicating that Resident. #84 was to have supervised assistance when ambulating and locomotion. Policy Review: Review of Policies and Standard Procedures-Fall Prevention and Management; Effective date: 05/25/21, revised 06/01/22; indicates that the Interdisciplinary Team (IDT) will review all information for all falls at the next Daily Clinical Meeting. The team should discuss the fall, interventions put into place and if they are effective. A deep root cause investigation should be discussed. The care plan should be reviewed to identify if interventions are appropriate or if new interventions should be added. A progress note of the discussion should be placed in the residents' chart. The team should have a way to inform all care givers of any new interventions placed on the care plan. The IDT team should review Risk Watch to assure the information is complete and accurate. Review of Policies and Standard Procedures-Neurological Checks; Effective date: 02/17/2000, Revised date: 06/21/18 and Reviewed Date: 05/30/19. It is the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The purpose of the policy is to guide the nurse in performing neurological checks, usually performed after a head injury or suspicion of a head injury from falls or blows to the head, but may be performed for other reasons in there is concern for vascular events including but not limited to cardiovascular accident (CVA or stroke), seizure activity or brain infections.