Failure to Ensure Staff Competency in Resident Transportation
Penalty
Summary
The facility failed to ensure that staff responsible for transporting residents possessed and demonstrated the necessary competencies to safely carry out their duties. Specifically, the facility's policy on transportation did not address requirements or training qualifications for staff performing resident transportation. Record review and staff interviews revealed that two CNAs who transported a resident from a hospital back to the facility had not received formal training, demonstration, or competency checkoff for the operation of the facility van, its lift, or the resident securement system. Both CNAs confirmed they had not been trained in the safe use of the securement system prior to the incident. During the transport, the resident, who had severe cognitive impairment and required assistance for transfers and mobility, experienced an incident where his wheelchair turned over backwards and landed on the floor of the van. The CNAs assisted the resident, who remained in the wheelchair, back to an upright position and completed the transport. The LPN evaluated the resident upon return and found no injury or complaints of pain. The incident was reported to the resident's representative, primary healthcare provider, and the Director of Nursing, and an incident report was completed. Further interviews revealed that the Maintenance Supervisor, responsible for training staff on the van and securement system, had just started in the position and had not yet provided any training. The DON stated she had only verbally explained the securement system to the CNAs without demonstration or requiring return demonstration. Personnel files for the CNAs involved showed no documentation of training specific to the operation of the facility van or securement system. The lack of formal training and competency verification directly contributed to the unsafe transport of the resident.