Health inspection·December 12, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was properly secured during transportation when: Residents Affected - Few 1. Seatbelt was loosely fastened unto Resident 1's wheelchair. 2. Footrest (a removable footplate where the feet are placed to avoid injury and maintain balance) was missing from Resident 1's wheelchair. These failures resulted in Resident 1 falling out of wheelchair, sustaining skin tear to right wrist and abrasion (scrape) to right shin. Findings: 1. During an interview on 11/13/23 at 12:45 p.m. with Licensed Vocational Nurse (LVN), LVN stated Resident 1 was taken to a doctor's appointment on 10/20/23, using the facility van. LVN stated on the way to the appointment, Resident 1's seat belt was placed too loose causing Resident 1 to slid out of the wheelchair and landing on his knees. During a concurrent observation and interview on 11/13/23 at 1:06 p.m. in Resident 1's room, Resident 1 stated during the car ride to the doctor's appointment on 10/20/23, the transport driver had to immediately hit the break on the van to avoid colliding into a car that had gone in-front of them. Resident 1 stated the sudden stop caused him to fall forward in between the front driver and passenger seat, landing on his knees. Resident 1 stated he was not buckled in properly. During a review of Resident 1's Minimum Data Set (MDS - a standardized, comprehensive assessment tool) dated 11/13/23, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status - which evaluates cognition, the ability to remember and think clearly) score of 14 (score range from 13-15 cognitively intact). During an interview on 11/14/23 at 4:10 p.m. with Activities Assistant (AA), AA stated on 10/20/23, she had transported Resident 1 using the facility van. AA stated another car had gone in-front of the van causing her to make a sudden stop. AA stated the sudden stop caused Resident 1 to slide out of his wheelchair, landing on his knees, with the lap belt ending up on his face. AA stated, the belt was too loose, that's how he fell. During a review of Resident 1's Nurse's Note (NN), dated 10/20/23 at 11:16 a.m. the NN indicated, Resident returned from appointment with skin tear to right lateral wrist and abrasion also noted with Page 1 of 2 056423 056423 12/12/2023 Gateway Post Acute 661 West Poplar Porterville, CA 93257

F 0689 abrasion to right shin. Level of Harm - Minimal harm or potential for actual harm During a review of the job description titled, Driver, undated, the job description indicated several duties including, Properly securing WC [wheelchair] bound residents into bays in Vans. Residents Affected - Few 2. During a concurrent observation and interview on 11/13/23 at 1:06 p.m. with Resident 1 in his room, Resident 1 stated he was transported to his doctor's appointment on 10/20/23, without footrest on his wheelchair. During an interview on 11/14/23 at 4:10 p.m. with AA, AA stated Resident 1 was transported to his doctor's appointment on 10/20/23, without footrest on his wheelchair. AA stated, I didn't ask the CNA [certified nursing assistant] to put it [footrest] on because it was running late. AA stated placing footrest on Resident 1's wheelchair could have made a difference in preventing Resident 1 from sliding off his wheelchair. AA stated, He is supposed to have one [footrest]. 056423 Page 2 of 2