The Illinois Department of Health has cited and fined Accolade Healthcare of Pontiac in Pontiac, IL when a certified nursing aide performed a mechanical lift transfer alone — without the required second staff member — causing a resident to fracture her left knee. The resident endured weeks of pain, multiple emergency room visits, and an initial misdiagnosis before a CT scan finally confirmed the fracture.
The resident at the center of this case was fully dependent on staff for all transfers and was cognitively intact — meaning she understood exactly what was happening to her and could clearly describe it. In the early morning hours, a certified nursing aide used a total body mechanical lift to transfer her without calling for a second staff member, as the facility’s own policy required. The resident described what happened in her own words: the aide “was pushing on me, then suddenly I heard a pop and a crack.” When she told the aide something was wrong, he responded, “Look, you’re standing up.” The resident replied, “I haven’t stood up in years.” Her feet were touching the floor and her left knee struck the side of the bed during the transfer.
The resident was sent to the hospital that same night complaining of pain above her left knee. She was given powerful pain medications including fentanyl and Norco. The emergency room performed an X-ray, which came back negative for a fracture, and she was discharged with a diagnosis of a sprain. But the pain did not go away. Over the following days she continued to complain, continued to receive pain medication, and continued to tell staff that something was seriously wrong. When the nurse practitioner assessed her days later, the resident stated plainly that the aide had hurt her and that she knew something was wrong and wanted an MRI. The nurse practitioner noted she could be referred to orthopedics — at which point the resident, exhausted and in pain, began demanding that something be done immediately, saying she was “tired of this place.”
It took nearly two weeks and an orthopedic appointment with a CT scan to get the answer the resident already knew: she had a fractured left knee. The initial emergency room X-ray had missed it entirely. Throughout that period she had been living with an undiagnosed fracture, managed with pain medication rather than appropriate orthopedic care.
When investigators spoke to the aide, he confirmed without hesitation that he had performed the mechanical lift transfer alone, without a second staff member. The Director of Nursing confirmed that two staff members were required and that the aide had received disciplinary action. The Assistant Director of Nursing was equally direct: “A two-person transfer is required for all staff when using a total body mechanical lift.” The facility’s own hydraulic lift policy stated explicitly that staff must obtain assistance from a second staff member before performing such a transfer. That policy was ignored, and a dependent, cognitively intact resident paid the price with a fractured knee and weeks of unnecessary suffering.
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.
