State Findings:
On 6/8/21 at approximately at 12:45 p.m., nursing staff were alerted that Resident #2 had a fall in the facility transport van during his return from his appointment. The facility failed to ensure Resident #2 was securely fastened in his wheelchair during transport to and from his appointment.
Upon return from his appointment the van driver (VD) #1 swerved to avoid hitting another vehicle and Resident #2 fell forward, out of his wheelchair, and sustained multiple fractures to his lower extremities.
Resident #2’s x-ray results indicated fractures in both left and right legs. The incident was reported to the State Agency.
Van Driver #1 was interviewed on 6/21/21 at 2:03 p.m. He said he had worked as a concierge prior to taking the van driving position and had basic transportation knowledge, so what he did to prepare himself to become the van driver was watch a tutorial online (name of social media channel), which gave him instructions on how to place and secure residents on the van.
However, he did not receive any formal training by the facility staff such as return demonstration of how to safely secure a resident in the facility van or complete the facility’s online training of how to safely secure a resident for transport.
He said the day of the incident, he placed Resident #2 in the van, locked his chair, and placed the floor locks to his wheelchair; however failed to place a seat belt/shoulder belt (which hung from the side of the van) to secure the resident in his wheelchair. He said he had not used that particular strap/belt prior to transporting residents and it did not occur to him to use those straps/belt (shoulder strap) because he thought the resident was just like a passenger in a bus which did not have seatbelts.
The NHA and director of nursing (DON) were interviewed on 6/21/21 at 3:10 p.m. They said VD #1 should have completed his training on how to secure residents before transporting residents. The NHA said he was the one responsible to ensure the VD #1 was trained. They acknowledged no one in the facility had followed up to ensure VD #1 had been educated on how to transport residents safely to their appointments prior to him accepting the position. They said moving forward the facility would ensure that staff were trained to complete assigned tasks/duties.
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Personal Note from NHA-Advocates
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