The Illinois Department of Health has cited and fined Arc at Bradley when, according to state investigators and facility records, a certified nursing aide transferred a resident from his bed to his wheelchair by herself and without the mechanical lift his care plan required, resulting in an impacted spiral fracture of his left upper arm that required hospitalization. The facility’s own investigation concluded the fracture was caused by the improper transfer, and two other aides told investigators that transferring this resident alone was something staff sometimes did.
The resident was a 70-year-old man who had lived at the facility for several years, with diagnoses including heart disease, chronic atrial fibrillation, hypertension, and a history of traumatic brain injury. His care plan, in place months before the injury, was explicit: he was dependent on two staff members for transfers using a mechanical lift. A subsequent assessment completed after the injury also documented that he was dependent on staff for transferring, and the Director of Nursing told investigators he was dependent on staff for all activities of daily living and unable to get in and out of his bed or chair by himself.
The injury was first brought to staff’s attention by a family member. According to the citation, she came to visit and touched the resident’s left shoulder. He jumped and told her his shoulder hurt. She reported it to his nurse. The nurse examined the shoulder, found it swollen, notified the physician, and an X-ray was ordered. The imaging showed an impacted spiral fracture of the left humerus. He was admitted to the hospital, seen by orthopedics, and discharged three days later with instructions to follow up with an orthopedic physician. When investigators observed the resident nearly two weeks after the injury, his left shoulder and upper arm were still swollen with purple discoloration.
The Administrator told investigators he had investigated the injury and determined that in the early morning hours before it was discovered, a certified nursing aide had transferred the resident by herself and had not used a mechanical lift — and that this was how the fracture occurred. He stated that when he interviewed the aide, she admitted she had transferred the resident by herself without the lift. He stated the resident requires two staff and a mechanical lift for all transfers, and that if the aide had used the lift with two staff, the resident would not have sustained a fracture. The Director of Nursing gave investigators the same account. The facility’s own addendum to its report to the state documented that the cause of the fracture was an improper transfer by facility staff.
The fracture pattern itself was significant. According to the citation, investigators were told that an impacted spiral fracture can only be caused by blunt force trauma, compression, and rotation occurring at the same time. The advanced practice registered nurse who reviewed the injury told investigators that the resident’s fracture was not caused by any medical condition, that it was caused by blunt force trauma, and that the improper transfer caused the fracture. She further stated that if staff had transferred the resident using two staff members and a mechanical lift, he would not have sustained a fracture.
Investigators found the practice was not isolated to a single aide. One certified nursing aide told investigators that the resident is a two-person mechanical lift transfer, but that sometimes staff — including herself — transfer him by themselves. A second certified nursing aide told investigators the same thing, stating that he is a two-person mechanical lift transfer but that sometimes he has had to transfer the resident by himself. The aide who performed the transfer that resulted in the fracture would not make herself available for an interview despite several attempts over two days. The facility’s own transfer policy states that mechanical lifting devices shall be used for any resident needing a two-person assist.
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.
