Alden Des Plaines Cited After Resident Dislocates Hip Prosthesis When Transferred by One Staff Member Instead of Two

The Illinois Department of Health has cited and fined Alden Des Plaines Rehab & Health Care when a certified nurse aide transferred an 83-year-old resident from the toilet to a wheelchair alone, despite the resident’s care plan requiring two staff members for all transfers due to his surgical condition and limited mobility. The resident experienced sudden weakness during the transfer, was lowered to the floor, and was subsequently found to have a dislocated right hip prosthesis, requiring hospitalization.

The resident, an 83-year-old man, had been admitted to the facility with a complex medical history that included a periprosthetic fracture around his right hip joint, a history of falling, osteoporosis, and the presence of an artificial right hip. Because of these conditions, the facility conducted multiple assessments upon his admission. A Fall Risk Assessment determined that the resident was at risk for falls. A functional abilities assessment documented him as a “dependent transfer,” meaning he could not transfer between surfaces on his own. A physical therapy evaluation further documented the resident as requiring “max assist out of bed and total dependence assist with transfers.” A restorative nurse confirmed that she assessed the resident’s transfer needs upon admission and that he was classified as a two-person assist “due to surgical site and having a wound vac.” Based on all of these evaluations, the resident’s care plan specified that all bed-to-chair transfers required “2-person assist using rollator walker using good side/left side to transfer.”

Despite these clearly documented requirements, only one certified nurse aide attempted to transfer the resident from the toilet to his wheelchair on the day of the incident. During the transfer, the resident experienced sudden weakness in his right leg and was lowered to the floor. A registered nurse responded after being called to the room and found the resident sitting on the floor. The nurse assessed the resident, who initially denied any pain, and together with the aide assisted him back to bed using a gait belt. However, when the resident was later reassessed for pain, he reported that he was “having pain to the right hip.” The nurse notified the physician and received orders for X-rays. The X-ray results confirmed that the resident’s right hip prosthesis had dislocated, and he was sent to the emergency room for further evaluation.

During the state’s investigation, the facility’s Director of Nursing confirmed that the resident “should have been a 2-person transfer assist” at the time of the incident. The Director also disclosed that the certified nurse aide involved in the incident “is no longer an employee at the facility for multiple reasons including resident safety.” The facility’s Administrator similarly confirmed that the aide “was suspended pending investigation and eventually was let go of the facility due to multiple factors.” The Administrator acknowledged that the fall was reported due to the resulting injury, and the resident was transferred to the hospital because of the hip dislocation and had not returned to the facility.

The facility’s own transfer policy states that “resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe transfers of residents.” The policy requires staff to “assess individual resident’s needs for transfer assistance on an ongoing basis” and to “document resident transferring and lifting needs in the care plan.” The facility’s fall management policy further requires that the facility “assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the residents plan of care in order to minimize the risks for fall incidents and/or injuries to the resident.” In this case, the hazards and risks had been properly assessed and documented, but the interventions were not carried out by the staff member responsible for the resident’s care.

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