The Illinois Department of Health has cited and fined Oakview Nursing & Rehab when staff improperly unloaded a resident from a transport van, causing the resident to fall three feet backward onto concrete because the wheelchair ramp was not properly engaged with the van. The fall resulted in two broken vertebrae, with hospital scans showing an unstable fracture, leading doctors to prescribe pain management and an immobilization brace for treatment.
The resident in question had multiple health conditions, including diabetes and difficulty walking.
According to facility reports, the resident “fell backwards from the exit door, coming to land on the ground.” The critical error was that the wheelchair ramp “was on ground level and not engaged with the van exit door” when staff attempted to unload the resident. The Transport Aide admitted she “assumed the staff member on the ground raised the lift, but she didn’t,” resulting in pushing the resident out of the van without proper support.
The resident provided a vivid account of the experience, stating she “fell three feet backwards onto the concrete” and “when her head hit the ground it felt like it exploded.” She reported ongoing dizziness and extensive bruising from the fall. The resident also shared that “she broke her back in two places” but doctors opted to try a brace rather than surgery.
Hospital records confirmed the severity of the injuries through CT scans, revealing “an acute fracture… along the superior endplate of T8 extending posteriorly to involve bilateral pedicles… resulting in mild anterior displacement of the vertebral body” and “a fracture of the anterior osteophyte at T7-8 disc space level.” The report emphasized that this “fracture is unstable.”
The Assistant Director of Nursing, who arrived after the incident, noted that the resident was initially calm but began “screaming and yelling in pain” when emergency medical technicians started moving her.
In response to this incident, the facility reported that “education on transportation safety was provided to all individuals involved in transportation and any disciplinary action needed has been completed.”
This case highlights serious safety concerns in resident transportation procedures, particularly regarding proper use of wheelchair ramps and communication between staff members.
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