Resurrection Place Nursing Home Aide Violated Safety Protocol, Causing Resident to Fall and Break Hip

The Illinois Department of Health has cited and fined Resurrection Place when a certified nurse aide attempted to transfer a resident using a mechanical lift without the required second staff member for assistance. The resident fell from the lift and suffered a displaced fracture of his left femoral neck, requiring surgical intervention and hospitalization.

The incident involved a resident with complex medical needs whose care plan clearly stated he “requires assistance partial to substantial assist with Activities of Daily Living” and specified “transfer with mechanical lift and 2 persons assist.” The resident had been admitted with a history of falls, displaced femur fracture, dementia, left-sided weakness from strokes, and walking difficulties. His functional mobility assessment indicated he needed “dependent assistance with chair/bed-to-chair transfer, sit to stand, toilet transfer.”

On the day of the incident, a certified nurse aide was assigned to care for the resident and was attempting to transfer him to bed using the facility’s mechanical lift. The aide later explained that she “noticed that the resident’s left foot was not on the base of mechanical lift, and she bent over to place it on the base when the resident let go from the grab bar with his right hand and slid off to the floor.” Crucially, the aide admitted she “was the only certified nurse aide in the room with the resident” and acknowledged that she “is aware that the resident is a two person assist and that when using any mechanical lift two-person assist is also required.” When asked why she proceeded alone, the aide explained that “the other staff were busy and could not get any help.”

The violation of protocol had immediate consequences. After the resident fell from the lift, the aide “assisted the resident back to the bed” and initially reported no injuries were observed. However, the next day the resident “complained of pain to his left hip.” X-rays revealed “a fracture to the left femoral neck,” and the resident was transferred to the hospital for emergency treatment and surgical repair.

Hospital records provided additional context about the severity of the incident. The resident “had called his wife and said that he was dropped into his bed and then after that was complaining of hip pain.” Due to his dementia, doctors noted he was “a poor historian,” but his wife confirmed that the resident “has been non ambulatory at the nursing home, they use a mechanical lift for mobility in and out of bed.” The resident underwent surgical intervention and was discharged back to the nursing home for skilled therapy with orders for “no weight bearing to lower left extremity.”

Multiple facility staff members confirmed that proper procedures were not followed. The registered nurse who responded to the incident stated that “when transferring with a mechanical lift the staff are supposed to have a two person assist” and the restorative nurse explained that “when using any Mechanical lift machine for transfers staff should be a two person assist” and confirmed “it is the facility policy when using a mechanical lift that two-person assist is implemented.”

The facility administrator acknowledged the policy violation, stating that “when staff is using a mechanical lift there should always be a two person assist per facility policy.” She admitted she “was unaware that only one certified nurse aide was transferring the resident” but confirmed she knew about the fall incident.

The nursing home’s own policies clearly established the safety requirements that were ignored. The Falls policy emphasized providing “an individualized, person-centered care approach” and stated that “residents who are at risk for falls will have an individualized care plan developed which identifies interventions to reduce fall risk.” The Fall Prevention policy aimed “to provide an environment that is free from accidents hazards” and “provide supervision and intervention to residents to prevent avoidable accidents.”

Despite these clear policies and the resident’s documented need for two-person assistance, a single aide attempted the transfer alone because other staff members were busy, resulting in a preventable fall that caused a serious fracture requiring surgery. The incident highlighted a dangerous gap between written safety protocols and actual practice that put vulnerable residents at risk.

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.