Hurricane Health: Driver Forgot Lap Belt, Broke Resident's Leg - UT

The incident happened on April 22 as the driver returned Resident 3 from a doctor's appointment to Hurricane Health and Rehabilitation. When a car stopped suddenly in front of the facility van, the driver hit the brakes hard. The 78-year-old woman with diabetes and muscle weakness slid forward from her wheelchair and struck both knees against the front seats.

She fractured her left femur.

The driver had secured all four points of the wheelchair to the van floor but missed the lap belt entirely. Federal inspectors found the facility failed to ensure safe transportation of residents, citing actual harm to the woman who spent days in intensive care.

Transportation Supervisor witnessed the aftermath when the van pulled into the facility parking lot minutes later. "When the van door was opened, it was apparent the resident had not been secured properly and the lap belt was not on," he told inspectors on July 30. "Resident 3 was in notable pain and paramedics were called."

The resident had moderately impaired cognition and required substantial assistance with mobility, according to her quarterly assessment completed three weeks before the accident. She used a wheelchair and needed maximum help moving around.

A facility nurse documented the injury at 12:26 PM that day: "Resident 3 had a fall in the transport van while returning from a doctor's appointment. The nurse documented that Resident 3 had an injury to her left knee and that the resident was sent to the emergency room."

But the injury was worse than initially reported. Hospital X-rays revealed an acute left distal femoral shaft fracture. The woman was admitted to intensive care for close monitoring and treatment of the broken leg.

Transportation Driver 1 initially told facility staff a different story. On the incident report filed at 4:28 PM on April 22, he explained "a car stopped right in front of him and he had to slam on his brakes. The resident [resident 3] slid out of her chair hit both of her knees and is feeling pain in both knee's."

Two days later, the driver admitted his mistake. In the follow-up investigation report filed April 24, he "explained that he neglected to put the lap belt on Resident 3 when transporting the resident back from an appointment." He confirmed he had "harnessed all four points of Resident 3's wheelchair, but he missed the lap belt strap."

The resident remained hospitalized for nine days. When she returned to Hurricane Health on May 1, a nurse documented extensive injuries: "a large left arm bruise, two left hip sutures, one left knee suture." She was cleared for weight bearing as tolerated.

The facility moved quickly to address the transportation safety failures. On the same day as the accident, administrators entered an agreement with an organization that manufactured wheelchair securement and occupant restraint systems. All transportation staff received new training on proper resident securement, including training videos from the contracted organization.

Staff had to sign training records and pass a post-training test. They also read and signed the Fleet Safety Program book on April 22.

Operations Manager explained the immediate changes during an interview with inspectors: "The facility immediately updated and revised their process for ensuring transportation staff were trained and monitored." The new system included "an observed daily check off for every transport to ensure the transportation driver did not forget anything before the facility van moved."

The facility also implemented a skills check requirement. Any driver who hadn't provided transportation services within 30 days had to complete "an observed check off" to ensure their abilities remained acceptable.

The Quality Assurance Performance Improvement Committee approved extensive monitoring protocols. The transportation supervisor would audit each driver's transport daily for two weeks, then three random days per week for one week, followed by one day per week. Random ongoing audits would continue indefinitely.

Weekly validation of driver securement procedures would last four weeks, then bi-weekly for two weeks, then three random audits monthly. The transportation supervisor had to report trends or concerns to the QAPI committee for 90 days, with immediate correction of any problems discovered.

Federal inspectors determined the facility's corrective measures addressed the transportation safety violations by April 23, 2024. The complaint inspection on July 30 found past noncompliance that had been resolved.

The resident's medical record showed she was initially admitted to Hurricane Health on an unspecified date and readmitted after her hospitalization. Her diagnoses included diabetes mellitus type 2, hypotension, muscle weakness, need for assistance with personal care, and difficulty walking.

Her Brief Interview for Mental Status score of 11 indicated moderately impaired cognition, according to federal assessment guidelines. The quarterly assessment from April 3 showed she required substantial to maximum assistance with mobility and used a wheelchair for movement.

The April 24 nursing note contained an error about which leg was injured. A nurse wrote that "Resident 3 sustained a right leg injury" and "an x-ray revealed Resident 3 sustained a right femur fracture." Federal inspectors noted the hospital radiology reports actually showed a left femur fracture.

Transportation Supervisor told inspectors the accident happened "on the road just next to the facility." When the van returned to the parking lot, he was waiting with a physical therapist, nurse, and operations manager. The severity of the resident's condition was immediately apparent when they opened the van door.

The woman's hospital discharge summary from May 1 documented her emergency room presentation for left knee pain evaluation. X-rays revealed the acute fracture, and she required intensive care admission for close monitoring and treatment of her injuries.

Hurricane Health's transportation safety protocols now require multiple layers of oversight and validation to prevent similar incidents. The facility retained all previous training while adding observed daily checkoffs, post-training examinations, and ongoing random audits of driver performance.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Hurricane Health and Rehabilitation from 2024-07-30 including all violations, facility responses, and corrective action plans.

Additional Resources

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