Staff has worked at the agency for approximately one year. She reported having some past experience in nursing home settings, which allowed her to feel comfortable working in a “medical home”. The medical home was described as having individuals who were higher medical needs than some other homes. She reported that some staff members would come into the home and leave, not understanding the level of work that was done in the home. 

At the time of the incident, the home was staffed with three staff members. This was recently increased as they admitted their fourth resident in the home a week to two weeks prior of the incident. She described that the individual involved in the incident was verbal, but had some limitations with speaking. She used a wheelchair, but staff described this as a hospital/standard wheelchair with no lap belt.

The day of the incident, the staff was bringing the individual to get labs drawn at the local clinic. However, once she got to the clinic, unloaded the wheelchair and went in; it was discovered that staff were at the wrong clinic. At this time the individual begun yelling and screaming in the wait area. Staff identified feeling increased anxiety as others were looking at them. She attempted to speak with the individual to calm her, but this did not help. She stated feeling “the crunch” at the time because she knew how important it is to get the individuals to appointments when they have them. She proceeded to load the individual in the van. She placed the wheelchair in the harnesses and was attempting to place the seat belt on. The staff identified difficulties with the seat belt, stating it was difficult to pull. [It wasn’t until further conversation with the supervisors following the debriefing that the seat belt was explained to be an airplane style seat belt that latched in front and would be pulled to tighten.] During this time, the staff stated that the individual was leaning forward and would not sit up properly. She believes the individual was able to scoot down out of her wheelchair and fell out. She stated the seat belt was at the ankles of the individual when they had fallen. Once she realized what happened, she pulled into a nearby parking lot and attempted to lift her; however, when that was unsuccessful, she called the house staff and explained what happened. They sent an employee over to assist with transferring the individual into the wheelchair and returned her to the foster home.

The staff stated she received VOC (vehicle orientation class) prior to being able to drive, but also following the incident. She states she tends to be the main driver in the mornings and feels she is a very safe staff, often double checking and taking her time to make sure mistakes don’t happen. She explained in the VOC training, they don’t use the hospital model wheelchair that this individual has but instead a different one. She further explained that it is difficult because each person is different and transporting each person has its own struggles, but the training doesn’t account for this.
