F0684

D

Failure to Assess Two Residents After Transport Van Motor Vehicle Accident

Overton, Texas Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that two residents involved in a motor vehicle accident (MVA) in the facility transport van were assessed for injury upon return to the facility, in accordance with professional standards of practice and facility policy. Resident #1, an older male with a history of focal traumatic brain injury with loss of consciousness, dementia with behavioral disturbance, and thoracic spine fusion, required substantial/maximal assistance with transfers and used a manual wheelchair for mobility. On the day of the accident, EMS documentation indicated no visible injuries, and the resident denied loss of consciousness, head strike, and use of blood thinners. A nursing progress note by LVN A documented that the van had been rear-ended, that police and EMS were called, that EMS evaluated and treated the resident, and that no injuries or pain were reported at that time. However, no nursing assessment or skin assessment was completed by facility staff upon the resident’s return after the accident.

For Resident #1, the following day a nursing note by LVN B documented that the resident, described as alert and oriented x4, complained of back pain and bilateral hip pain following the MVA. Subsequent documentation noted continued complaints of stiffness and mild pain, and x‑rays of the cervical spine, bilateral hips, and lumbar spine were obtained, which showed no acute changes. Despite these later assessments, record review showed that a facility skin assessment was not completed after the accident. Interviews further clarified that Resident #1’s family member believed he should have been sent to the hospital after the accident and reported that, upon arrival back at the facility, the resident had to crawl out of the side of the van due to a non-functioning wheelchair ramp. The family member also reported bruising to the resident’s right index finger and left cheek and eye area the day after the accident. Resident #1 himself stated that EMS only asked from the front of the van if he was alright, that he reported feeling fine at that time, that no one asked if he wanted to go to the hospital, and that he had to crawl over a seat to exit the van when he returned to the facility.

Resident #2, an older male with diagnoses including malignant neoplasm of the colon, history of transient ischemic attack and cerebral infarction, and age-related cognitive decline, had a significant change MDS showing severe cognitive impairment with a BIMS score of 3 and required supervision/touching assistance with walking. EMS documentation for Resident #2 on the day of the accident also indicated no visible injuries, denial of loss of consciousness, denial of head strike, and no use of blood thinners. A nursing progress note by LVN A documented that the van was rear-ended, that police and EMS were called, that EMS evaluated and treated the resident, and that no injuries or pain were reported, with the NP and responsible party notified. However, similar to Resident #1, there was no documented nursing assessment for injury upon return to the facility immediately after the accident. A skin assessment for Resident #2 was not completed until several days later and showed no skin issues. In interviews, Resident #2 reported that no one checked him at the scene or upon return to the facility and that he was sore for a few days after the wreck.

Staff interviews confirmed that facility nursing staff did not perform post-accident assessments on the residents when they returned from the MVA. LVN A stated that she did not assess either resident for injury upon return because she believed EMS had evaluated and cleared them at the scene. The ADON reported that she received a call about the wreck, was told the residents were okay, and asked if they had been checked, but there was no documentation of an immediate post-accident assessment by facility nurses. The transporter, a CNA serving as a backup driver, stated that she was instructed by the administrator and DON to have EMS check the residents, that she was speaking with police and could not see whether EMS evaluated the residents, and that EMS told her they were free to go. She also confirmed that the back of the van would not open and that she and CNA C had to get Resident #1 out through the side door. The Administrator stated she believed the residents were evaluated at the scene and cleared with no injuries and referenced skin assessments she believed were done, though none were provided prior to surveyor exit. The facility’s policies on transportation and change in a resident’s condition required procedures for safe transportation and nursing observation and documentation when there is a change in condition, but the records showed that immediate post-accident assessments were not completed for the two residents involved in the MVA.