Resident Fall and Injury Due to Improper Van Securement and Unqualified Staff Transport
Penalty
Summary
A deficiency occurred when a resident dependent on renal dialysis and with difficulty walking was transported to a dialysis appointment in the facility van, which lacked the required safety equipment and was operated by unqualified and untrained staff. The van did not have a shoulder harness as required by federal regulations, only a lap belt, and the wheelchair securement system did not meet ADA Accessibility Specifications for Transportation Vehicles. The maintenance aide, who was not a certified nursing assistant and had not completed the required Facility Vehicle Driver Training Program or pre-trip inspection, was instructed to transport the resident despite expressing discomfort and lack of experience. During transport, the aide improperly secured the wheelchair, resulting in the wheelchair tipping and the resident falling forward, striking her head and sustaining a skin tear. After the fall, the aide did not immediately inform the dialysis facility staff of the incident, and the resident proceeded with her dialysis appointment without assessment for injury at that time. Upon return to the facility, the resident was found to have a head injury and a skin tear, and was subsequently sent to the emergency department for evaluation. The emergency department documented a closed head injury, moderate to severe pain, and possible concussion symptoms. The facility's records confirmed that the staff members assigned to drive the van were not CNAs as required by the facility's job description, and had not completed or documented the necessary training prior to transporting residents. Interviews with facility staff and review of documentation revealed that the van's securement system was not compliant with federal safety standards at the time of the incident, and that the required pre-trip inspection and training protocols were not followed. The maintenance aide admitted to not knowing how to properly secure the resident and not performing the required safety checks. The facility's own policies required CNA certification, CPR certification, and completion of a vehicle driver training program for anyone transporting residents, none of which were met in this case. The lack of proper equipment, training, and communication led directly to the resident's fall and injury during transport.