RALEIGH, NC - A federal inspection completed on May 8, 2025, found PruittHealth-Raleigh in immediate jeopardy status after a contracted transport driver failed to properly secure a resident's wheelchair, causing a fall that resulted in a lumbar spine fracture. The driver then moved the injured resident without medical assessment and did not report the incident to facility staff.
Unsecured Wheelchair Leads to Spinal Fracture
On April 25, 2025, a resident identified in inspection documents as Resident #1 was being transported back to the Raleigh facility following a dialysis appointment. The contracted transport driver loaded the resident, who uses a wheelchair due to bilateral leg amputations, into the transportation van at approximately 4:30 pm.
According to the driver's own statement obtained during the investigation, he was in the process of securing the wheelchair when a person from the dialysis center approached him. The driver stopped what he was doing to receive something from the dialysis staff member, then closed the van doors and began driving without realizing he had not secured the wheelchair to the floor.
Manufacturer instructions for wheelchair tie-downs require a minimum of four anchor points: two at the front and two at the rear of the chair. The driver is required to connect tie-down straps to floor anchor points and then to the wheelchair's securement points, tightening them to ensure the wheelchair is firmly secured before driving.
When the driver took a turn, the unsecured wheelchair tilted backwards. The resident reported that she felt her chair tip and then could only see the ceiling of the van. Her wheelchair landed with its backrest on the van floor while she remained seated in the chair, causing her head to strike the floor and her back to sustain impact.
The resident reported pain at the maximum level of 10 out of 10 affecting her neck, shoulders, and back upon returning to the facility at approximately 5:30 pm. Staff documented that she was moaning and crying out and continued to yell out in pain while awaiting emergency transport. One nurse aide stated she had never seen the resident in pain like that before.
Hospital imaging initially showed no acute findings on CT scans performed on April 26. However, due to continued pain complaints, an MRI was performed on April 29 and revealed a fracture at the superior endplate of L1 - the first vertebra of the lumbar spine region. The resident was discharged on May 1 with prescriptions for oxycodone and a lidocaine pain patch.
Driver Moved Injured Resident, Failed to Report Incident
The inspection identified a second immediate jeopardy violation related to the driver's actions following the fall. Rather than calling 911 to have the resident assessed by medical professionals, the driver manually lifted both the resident and her wheelchair from the floor, set them upright, and continued driving to the facility.
Moving a person after a fall without first having them assessed by a qualified medical professional presents significant risks. Spinal injuries in particular can be worsened by improper movement, potentially causing additional damage to the spinal cord or surrounding structures. The inspection report noted there was a "high likelihood of further injury from moving a resident after a fall prior to a clinical assessment."
When the driver arrived at the facility, he approached the nursing station with the resident and reported only that her back hurt and she wanted to go to bed. He left the dialysis communication book at the desk and departed the facility without disclosing that the wheelchair had tipped over or that the resident had hit the floor of the van.
The resident herself informed facility staff what had occurred. During her May 8 interview with investigators, she stated: "During the entire ride back to the facility after the fall the Contracted Transport Driver kept saying he was going to be fired for what happened."
By failing to report the incident, the driver delayed the resident's access to appropriate medical evaluation and treatment. The facility nurse who assessed the resident noted she appeared "panicked, like talking all over the place and rambling" and seemed "hesitant to report what happened, almost nervous."
Medical Significance of the Violations
Lumbar vertebral fractures in elderly patients can have serious consequences for mobility, independence, and quality of life. The L1 vertebra is located at the junction between the thoracic and lumbar spine, a region that bears significant mechanical stress during normal movement.
Superior endplate fractures occur at the top surface of the vertebral body, where the intervertebral disc connects. While the hospital noted this fracture was "without height loss" - indicating the vertebra had not collapsed - such injuries typically require pain management, activity modification, and monitoring for complications.
The resident's medical history made this incident particularly significant. She had bilateral leg amputations (above-knee on the left, below-knee on the right) and was dependent on dialysis. Prior to the incident, her pain medication use was limited - records showed she used as-needed tramadol 11 times and ibuprofen twice in the weeks preceding the fall.
Following the injury, her pain management needs increased substantially. Hospital records documented she required oxycodone for moderate to severe pain, receiving it nine times in the first six days after returning to the facility. Rehabilitation evaluation on May 2 noted "significant" pain across her shoulders and lumbar area.
The resident's physician, who had treated her for over three years, stated during his interview that she "was very sharp and alert" and "a reliable source of information." He indicated that the resident should have been assessed before being moved since the driver "was not able to know if Resident #1 had been injured at the time and it could have worsened an injury."
Contracted Transportation Company Terminates Driver
The contracted transportation company conducted its own investigation following the incident. The company owner interviewed the driver and provided a written statement to the facility on April 25, the same day as the incident.
The company's statement confirmed that the driver did not follow policy by failing to secure the passenger's wheelchair and failing to notify 911 to assess the resident for injury prior to moving her. The driver was terminated for "gross negligence" and deemed ineligible for rehire.
The facility ceased using this transportation company entirely as of May 5, 2025.
Immediate Jeopardy Removed Following Corrective Actions
State surveyors notified the facility administrator of immediate jeopardy status on May 5 at 4:51 pm. The facility implemented a removal plan that was validated on May 8, though the facility remains out of compliance at a lower severity level pending verification that corrective measures are effective.
Corrective actions included:
For the remaining contracted transportation company: - All drivers completed training on May 6-7 regarding wheelchair securement using manufacturer instructional videos with return demonstrations - Training on calling 911 to assess residents before moving them after a fall - Training on identifying and reporting neglect - New drivers must complete training before being assigned facility transportation
For facility staff: - 100% of staff received re-education on not moving residents after falls until examined by a licensed nurse - 100% of staff received training on abuse and neglect identification and reporting - The Clinical Competency Coordinator will track training completion
Resident safety audits: - The Director of Nursing reviewed all falls within the past 30 days to verify proper assessment protocols were followed - Social workers interviewed cognitively intact residents who had used transportation services in the past 30 days - Licensed nurses completed skin and pain assessments for cognitively impaired residents transported in the past 7 days - No additional concerns were identified
The facility's transportation staff also received competency training from the Maintenance Director on manufacturer guidelines for securing wheelchairs, including return demonstrations.
Additional Issues Identified
The inspection cited the facility under three federal regulatory tags, all at the immediate jeopardy level:
- F600: Protection from abuse and neglect - The failure to have the resident assessed before moving her and the failure to report the incident to facility staff constituted neglect - F684: Quality of care - The resident did not receive appropriate treatment following the fall due to the driver's failure to report the incident - F689: Accident hazards - The failure to properly secure the wheelchair created an unsafe condition
The facility is disputing all three citations, according to the inspection report.
Surveyors interviewed multiple staff members who were present when the resident returned from dialysis. One nurse aide reported that when she saw the driver pushing the resident down the hall, the resident was "sitting slumped down, unable to sit upright in the chair with her lower body close to the front edge of the wheelchair and her neck resting on the back of the chair." The aide attempted to speak with the resident but the driver continued pushing the wheelchair without stopping.
The resident remained at the facility as of the May 8 inspection and continued to experience pain from the incident. During her interview, she stated "it was hard to describe just that she felt pain all over her body."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pruitthealth-raleigh from 2025-05-08 including all violations, facility responses, and corrective action plans.
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