The Illinois Department of Health has cited and fined Serenity Estates at Morris in Morris, Illinois when a resident fell backward out of his wheelchair while being transported in the facility’s van and sustained a subdural hematoma and a fracture. State investigators determined the facility failed to ensure the resident was properly secured in his wheelchair during transport.
The resident, an 83-year-old man, had diagnoses including chronic congestive heart failure, chronic kidney disease, chronic peripheral venous insufficiency, metabolic encephalopathy, and an anxiety disorder, and required assistance with personal care. His care plan documented that he received a blood thinner due to atrial fibrillation. The facility’s medication administration record for that month shows he was receiving a blood thinning medication twice daily through the day before the fall. The facility’s fall incident report, completed the day of the fall, notes that he was taking a blood thinner, and a physician’s progress note from that same day refers to him as receiving a blood thinner for atrial fibrillation.
The resident was being transported back to the facility from a medical appointment in the facility’s van when the fall occurred. Accounts of how it happened differ across the records. The facility’s final incident report states the resident was seated in a wheelchair and secured in the vehicle, and that during the trip his wheelchair became unstable, shifted backward, and he came into contact with the floor. A physician’s progress note states that nursing reported his wheelchair tipped over. The ambulance report states the van driver said the resident fell backwards while secured in his wheelchair and hit his head, and that paramedics found all four wheels strapped down with the resident thrown backwards out of the wheelchair, one shoulder strap still around his shoulder. Hospital records describe the fall as occurring when the harness became loose and note the fasteners on the wheelchair had come loose.
The activities aide who was driving the van told investigators she heard the resident make a sound, looked behind her, and could not see him. She said that when she asked where he was, he answered that he was on the floor. She said she pulled over and found him lying on his right side facing the back door, with his feet over the ramp and his seat belt still fastened.
The resident told investigators he was heading back to the facility after an appointment when his wheelchair went backwards and he fell, hitting his head. He said he must have passed out, because when he woke up he was in an ambulance. He reported ongoing head and neck pain requiring daily pain medication, which he rated a 7 out of 10, along with episodes of dizziness. He said that since the fall he cannot do much beyond attending therapy and is unable to participate in activities, and that being transported in the facility’s van again on the day of his interview made him feel dizzy and sick.
Hospital records show the resident arrived at the emergency department with complaints of head, right shoulder, and low back pain. His diagnoses included a subdural hematoma, a closed head injury, a fracture, and a contusion. The record does not specify the location of the fracture.
The facility’s medical director stated the resident sustained a brain bleed after the fall. She said she believes he may have been on blood thinners at the time, which increases the risk of bleeding from an injury, and that she believes nursing reported he hit his head. She described the fall as sounding “pretty bad,” said the resident was out of the facility for a period afterward, and said that when she spoke with him following the fall he still had pain and headaches. She also stated that if a resident is not secured while being transported in a vehicle, it could increase the risk of injury or a fall.
The activities aide told investigators that she had ridden in the facility’s bus a couple of times with a former activities aide and once with a former maintenance staff member and had observed the process of transporting residents, but had never received formal training. She said the hooked straps used to secure the resident’s wheelchair do not have a locking mechanism but tighten when tugged. When asked to demonstrate on the van how she had secured the wheelchair, she placed four of the van’s built-in hooked straps on the wheels of an empty wheelchair.
The facility’s administrator stated that the former activities aide and the former maintenance staff member had been responsible for training staff on resident transportation. She described the training as including review of a safety transport checklist and a transport book covering items such as checking the bus and wheelchairs for safety, ensuring the seat belt is securely fastened, ensuring residents are comfortably and securely positioned, and placing four hooks on the wheelchair — two in front and two in back — secured to the frame of the chair, with staff tugging on the hooks to confirm they are locked in position. She said staff being trained would be expected to observe these procedures and then perform a return demonstration, and that staff would be expected to raise questions or concerns about their training. She confirmed that if staff are not trained properly it may contribute to residents being injured during transport, and agreed that residents could be injured if staff do not follow training instructions.
The administrator stated that a safety checklist has always been in place for the facility’s transportation van, but she was not able to provide investigators with a copy of the checklist completed on the day the resident was transported.
The facility’s written transportation protocol states that its purpose is to ensure the safe transportation of residents by facility employees, and directs staff to secure wheelchairs using approved tie-down systems and occupant restraints and to ensure all residents are safely seated and secured before the vehicle moves. The facility’s sample transportation safety checklist includes tasks for the wheelchair to be secured by the frame and for the resident’s seatbelt to be secured.
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.
