PruittHealth-Raleigh: Transport Driver Spinal Fracture - NC
The resident suffered a fracture at the superior endplate of her L1 vertebra after her wheelchair flipped backwards during transport from dialysis on April 25. She rated her pain at 10 out of 10 and required hospitalization and opioid pain medication.
The contracted transport driver never reported the fall when he returned the resident to the facility at 5:30 pm. Instead, he told the nursing station only that the resident's back hurt and she wanted to go to bed before leaving the building.
"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," the resident told inspectors during a May 8 interview.
The resident, who has severe cognitive impairment and uses a wheelchair due to bilateral leg amputations, had to report the incident herself to nursing staff once she was back in her room. Nurse #2 found her "panicked, like talking all over the place and rambling" and "hesitant to report what happened, almost nervous like not looking at her when she asked her about what happened on the ride back from dialysis."
Staff had never seen the resident in such pain. Nurse Aide #3, who was normally assigned to the resident, stated "when she went to Resident #1's room she noticed immediately something was wrong by the expression on Resident #1's face, just looked different." The aide said the resident "was crying out every time she was touched and she had never seen Resident #1 in pain like that."
The driver's written statement to his company revealed he was distracted while loading the resident into the van. He reported he was "about to secure her for travel when he was distracted by a person from the dialysis center" and "stopped what he was doing to get something from the person from the dialysis center, then he secured the lift, shut the doors, and took off without realizing he had not secured Resident #1's wheelchair to the floor."
When the wheelchair tipped backwards, the resident remained seated as both she and the chair hit the van floor. Her head struck the floor and her back sustained impact when the wheelchair's backrest hit the ground.
The driver pulled over, asked if she was okay, and lifted both the resident and wheelchair upright while she was still seated. He then secured the wheelchair and drove her back to the facility. According to his statement, the resident asked him not to tell anyone because she didn't want to get anyone in trouble.
The resident described the experience differently. She told inspectors she "could not even say anything at that time" and "felt confused and in shock." During the ride back, "her pain continued to get worse and when she got back to the facility her pain was at least a 10 out of 10."
Nurse Aide #1, who was working when the resident returned, observed that "the Contracted Transport Driver came to the nursing station desk and he reported that Resident #1 had been crying like this and was not feeling good." She noted the resident "was visibly upset" and later said the driver "had the audacity to stand right in front of her face and not say one word about what happened to Resident #1 in the van when it was obvious Resident #1 was in extreme pain."
Another aide, NA #4, saw the driver pushing the resident down the hall and noticed she 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 resident "appeared to be upset and in pain because of the way she was sitting in the wheelchair."
Nurse #2 administered two 50-milligram tramadol tablets at 5:45 pm but the resident "continued to yell out in pain." The nurse contacted the resident's physician, who ordered emergency transport to the hospital. EMS arrived within ten minutes and transported the resident at 6:45 pm.
Hospital records show the resident reported pain throughout her head, neck, chest, abdomen, and back. Initial CT scans on April 26 showed no acute findings, but continued pain prompted an MRI on April 29 that revealed the L1 fracture. She remained hospitalized until May 1 and was discharged with oxycodone for moderate to severe pain and lidocaine patches.
The resident's physician, who had treated her for over three years, told inspectors the resident "was very sharp and alert" and "normally very clear in her cognition and speech and she was a reliable source of information." He said the driver "should have been assessed before being moved since the Contracted Transport Driver was not able to know if Resident #1 had been injured at the time and it could have worsened an injury."
Director of Nursing tried to locate the driver after learning of the incident but "when she went to find the Contracted Transport Driver he had already left the facility so she was unable to obtain a statement."
The transportation company terminated the driver "due to not reporting the incident, not securing Resident #1's wheelchair, and gross negligence" and made him "ineligible for rehire."
Federal inspectors cited PruittHealth-Raleigh for immediate jeopardy to resident health and safety, noting there was "a high likelihood of further injury from moving a resident after a fall prior to a clinical assessment of injury and not informing staff of the fall delayed treatment for the resident."
The facility's administrator initially filed a neglect report with the state but told inspectors she "did not feel the facility was responsible for the actions of the Contracted Transport Driver" and "did not identify anything, on their end, that the facility would have done differently."
PruittHealth-Raleigh terminated its contract with that transportation company on May 5. The facility implemented new training requirements for all transport drivers, including education on calling 911 to assess residents for injury before moving them after any fall and mandatory reporting of incidents to facility staff.
The resident returned to PruittHealth-Raleigh on May 1 and continued requiring pain medication through early May. Rehabilitation staff noted on May 2 that her "pain was reported as significant across her shoulders and lumbar area."
During her final interview with inspectors on May 8, the resident said she "still had pain from the incident" and "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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PruittHealth-Raleigh in Raleigh, NC was cited for violations during a health inspection on May 8, 2025.
The resident suffered a fracture at the superior endplate of her L1 vertebra after her wheelchair flipped backwards during transport from dialysis on April 25.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.