Lutheran Care Center Resident Falls From Mechanical Lift And Dies When Strap Broke

The Illinois Department of Health has cited and fined Lutheran Care Center when a hospice resident fell headfirst to the floor after a mechanical lift strap broke during transfer by a single nursing assistant instead of the required two staff members, causing a head injury and rapid decline that led to her death three days later. The facility violated its own policy requiring two staff present during mechanical lift transfers due to weekend staffing shortages.

The resident in question was admitted under hospice care with heart failure, stroke, pneumonia, and respiratory failure. She was completely dependent on staff for all care including transfers. Her care plan required “transfers using mechanical lift and 2 staff assist.”

During a morning transfer, a nursing assistant was alone using a mechanical lift when “the strap broke and the resident fell to the ground headfirst hitting her head.” The incident report documented: “Right blue upper strap broke with resident over the floor. She fell out of sling laying on her right side x 2 raised areas on upper back of head and 1 raised area on upper right side of head.”

The responding nurse found the resident “still alert as her normal” with knots on her head and right arm bruising. Initial vital signs showed respirations 32 and oxygen saturation at 84%.

The resident’s condition rapidly deteriorated. She developed respiratory distress and “had 2 large emesis undigested food” with pulse 130 and oxygen level at 88% even with supplemental oxygen. Hospice ordered comfort medications. By the next midnight, nursing notes documented: “Resident opens both eyes, no verbal response, grimaces with touch. Pupils sluggish. No response when asked to squeeze hands. 7 centimeter round soft area to upper crown of head.”

By afternoon: “Resident non to minimal responsive. Does not open eyes, pupils sluggish.” The following morning, she was “non-responsive, bilateral extremities flaccid.” Early the next morning, a nurse found her “no audible pulse, no audible blood pressure, respirations ceased.” She died three days after the fall.

The hospice nurse stated directly: “Yes definitely” the fall contributed to death. “She had a rapid change in condition that consisted of a change and decrease in her level of consciousness, she began to have vomiting, and inability to eat and keep food down.” When asked if the resident was at end-of-life prior to the fall: “I do not feel like she was at that point prior to the fall. She was not in the condition yet that I would have talked with the resident’s family to inform them that death was near or even a month away.”

The facility physician confirmed: “With a head injury to a resident of her age it is never good.” When told the hospice nurse felt the fall attributed to death, he stated: “I have to agree with Hospice on that statement.”

The administrator stated: “We know the fall caused the change in condition and death of the resident.”
The nursing assistant admitted “using 1 staff member for mechanical lifts was not unusual on the weekends due to staffing shortage but she will never do that again.”

The facility’s policy required “2 staff members to maintain resident’s safety during transfers.” The facility’s report acknowledged: “In our initial report, it was reported that there were 2 CNAs present. During our investigation, it was noted that there was one CNA at the time of the transfer and fall.”

The death certificate listed cause of death as “respiratory failure with hypoxia.” The coroner stated she “was unaware of the resident falling out of a mechanical lift causing a head injury that led to death” and that “the death certificate should have cause of death was accidental.”

The facility violated its policy requiring two staff members during mechanical lift transfers due to weekend staffing shortages. A hospice resident who hospice confirmed was not at the end of life suffered a traumatic head injury when dropped headfirst from a lift and died three days later.

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 Chicago 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.