**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff and Medical Doctor interviews, the facility failed to evaluate a resident’s condition by a licensed professional before moving a resident following a fall in the facility’s transport van for 1 of 2 residents sampled for assessment after an accident (Resident #1). Resident #1 experienced a Cervical (C2-C3) fracture to the neck and expired at the hospital.

Review of a Witness Interview Form dated [DATE] and signed by TA #1’s Supervisor (who was over medical records and transportation scheduling) revealed a call came to her on [DATE] at 5:24 PM from TA #1 who said Resident #1 had fallen out of his wheelchair. He said a vehicle had cut him off and he had to slam on the brakes causing Resident #1 to hit the van floor. TA #1 said, the resident was strapped in, but not sure how it came loose. He said Resident #1 was bleeding around the head area. I told him to call 911. I called the DON and told him what had happened. The DON said, we have to go get the van because TA #1 cannot drive the van. When we (DON and I) arrived at the station, the paramedics were already there assessing Resident #1. The DON walked on the driver side of the van to see what was going on with Resident #1. I looked at Resident #1, knowing that he had just completed his [MEDICAL TREATMENT] treatment and saw that his eyes appeared weak/sleepy-like and blood covering his bottom teeth. He looked to me and was trying to say something, but his words were not clear. At approximately 6:00 PM, Resident #1 was transported to the local hospital.

Review of a Certificate of Death with date of death of [DATE] revealed Resident #1’s immediate cause of death was multiple [MEDICATION NAME] force injuries. Description of how injury occurred revealed motor vehicle stopped abruptly throwing unrestrained passenger forward.

During an interview with the Administrator and the Executive Director on [DATE] at 12:32 PM they confirmed TA #1 should not have moved Resident #1 following the incident on [DATE] prior to being assessed by a licensed staff member or EMS. The administrator and Executive Director provided the following plan of correction with a compliance date of [DATE].