Health inspection·June 11, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Resident #115, who had cognitive and neurological impairments, a diagnosis of dementia, and was at risk for falls, was not left unattended in the facility van with no air conditioning and the door open for an extended period of time. This affected one resident (#115) of three residents reviewed for transportation to outside appointments. The facility census was 67. Findings include: Resident #115 was admitted to the facility on [DATE] with diagnoses including left breast wound, left breast cancer, dementia, multiple sclerosis, heart disease, chronic kidney disease, depression, anxiety, and psychosis with delusions. Review of the admission MDS (Minimum Data Set) Version 3.0 Assessment Tool dated 05/17/24, Resident #115 had a BIMS (Brief Interview for Mental Status) of 10/15 indicating moderate cognitive impairment. Review of Resident #115's care plan initiated on 05/11/24 indicated Resident #115 had impaired thought processes related to cognitive and neurological impairments from dementia and Multiple Sclerosis. Resident #115 was at risk for falls and poor decision-making. Resident #115 was to receive facility-provided transportation to medical appointments. routine radiation treatment for breast cancer that required transportation to appointments. The facility provided a van/bus for transportation for Resident #115 to attend appointments. On 06/04/24, Resident #115 was scheduled to be transported from the facility to a medical appointment scheduled at 2:00 P.M. that same date. During interview on 06/05/24 at 11:04 A.M., Employee #301 stated that he refers to the Transportation book that tells him who, what time, and where someone needs to be transported. Employee #301 stated he had two residents scheduled to be transported to the hospital for appointments on 06/04/24. Resident #115 had an appointment scheduled at 2:00 P.M. Resident #151 had an appointment scheduled at the same hospital at 2:30 P.M. Employee #301 stated that he first loaded Resident #115 onto the transport van and applied her seat belt. He then lowered the wheelchair lift to go get Resident #151. He stated he left the bus door open. When he went to get Resident #151, she was not ready and needed to be changed. Employee #301 then stated that he went to find Resident #151's nurse but finally decided he could not wait any longer and had to go take Resident #115 to her appointment. Employee #301 Page 1 of 2 366377 366377 06/11/2024 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0689 Level of Harm - Minimal harm or potential for actual harm stated he arrived at the hospital and let Resident #115 out and went inside to help her sign in and passed his number to the secretary to call and let him know when she was ready to be picked up. Employee #301 confirmed that he did not arrive at the hospital at the scheduled appointment time. Employee #301 also confirmed that he did not leave the air conditioner on while Resident #115 sat in the transport van for 20 to 30 minutes. Residents Affected - Few During interview on 06/05/24 at 3:05 P.M., Resident #115 indicated she was left on the facility transport van for approximately 20 to 25 minutes, with the doors open but no air conditioning with an outdoor temperature of 85 degrees Fahrenheit. Resident #115 stated when she finally arrived late to her medical appointment, she had a headache and was sweaty. This deficiency represents non-compliance investigated under Master Complaint Number OH00154527. 366377 Page 2 of 2