The Illinois Department of Health has cited and fined Fair Havens Senior Living in Decatur, Illinois when a resident’s wheelchair was improperly secured in the facility’s transport van by a driver who had not been adequately trained on the manufacturer’s wheelchair securement system, causing the resident’s wheelchair to flip forward and the resident to slide onto the floor of the van as it drove down a hill, resulting in multiple leg fractures and a 17-centimeter laceration requiring eight sutures. The state issued an Immediate Jeopardy citation, the most serious level of violation.
The resident at the center of this case used a wheelchair for mobility and required staff assistance for her activities of daily living. She was being transported to a physician appointment in the facility’s transport van. The van driver loaded her into the van, secured her wheelchair, fastened the lap belt, and began driving down the hill in front of the facility. Almost immediately, the resident later told staff, she felt her wheelchair move and called out to alert the driver. The driver told her she would be ok and continued driving.
Within moments the resident was screaming. The driver looked in her rearview mirror and saw the resident leaning forward in the wheelchair, bracing herself against the seat next to her. The driver later said in her own words: “I was pulling away from the building when I heard her screaming. I looked in the rearview mirror and saw her leaning forward in the wheelchair, bracing herself on the seat next to her. I drove back around to get help; she couldn’t hold herself up. Her leg went back underneath her, and blood was everywhere.” Rather than stopping immediately, the driver drove the van around the parking lot back up the hill to the facility’s main entrance to get help.
When the Director of Nursing and a licensed practical nurse reached the van, they found a scene the nurse later described as resembling a car accident. The wheelchair had tipped forward. The resident was on the floor of the van with her left leg bent under her body, blood pooling beneath her. The seatbelt and wheelchair attachments were under such tension from the resident’s body weight that staff had difficulty unlatching them. Once they freed her and placed her flat on the van floor, they discovered a large laceration to the top of her left shin. She was alert and oriented and complained of severe pain in her left leg. Emergency Medical Services arrived and transported her to the hospital. Imaging revealed multiple fractures: a fracture of the upper tibia, a fracture of the fibular head, a fracture of the distal fibula extending to the ankle, and an additional avulsion fracture. The 17-centimeter laceration on her leg was closed with eight sutures.
The investigation revealed that the driver had not been properly trained on the manufacturer’s wheelchair securement system. When investigators observed the driver loading another resident into the van for transport, she attached the securement straps to the wheelchair’s armrests rather than the wheelchair frame, used straps that were twisted, and positioned the straps at a 65-to-75-degree angle. The manufacturer’s manual specifies that the tie-down hooks must be attached to a solid wheelchair frame — explicitly not to spokes, wheels, or movable components — and at an approximate 45-degree angle. The driver acknowledged she had attached the restraints to the armrests and stated this was how she always restrained residents for transport.
When asked about her training, the driver stated she had not been formally trained on driving the van or securing residents and had only received a packet with a safety checklist. The Maintenance Director, who was listed as her trainer, was unable to give an accurate demonstration of the actual securement system used in the transport van, demonstrating instead a different system. He acknowledged the j-hooks should be attached only to the wheelchair frame, not the armrests. The driver’s training records included a form dated the day after the incident that was a photocopy with the trainer’s signature already on it and the driver’s name handwritten in. The driver confirmed she had not actually received the training documented on that form. A third resident interviewed by investigators stated the same driver had restrained his wheelchair using the armrests as the anchoring point on multiple prior occasions. The Administrator confirmed the facility did not have a transportation policy at the time of the incident.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
