The Illinois Department of Health has cited and fined Elevate Care Country Club Hills when a certified nursing aide transferred a resident who required two-person assist for all transfers without a second staff member present, causing the resident to slide to the floor and sustain a fractured left ankle requiring hospitalization. The resident’s care plan had clearly documented the two-person transfer requirement, and multiple assessments had confirmed she was fully dependent on staff for transfers — but the aide performed the transfer alone.
The resident was a 57-year-old woman with a complex set of diagnoses including cerebral palsy, spastic hemiplegia, vascular dementia, schizophrenia, bipolar disorder, and generalized anxiety, among others. She had been a long-term resident of the facility. Her condition included significant weakness on her left side, and she wore an Ankle Foot Orthosis brace on her left foot to support her mobility. Multiple assessments documented over the preceding months consistently showed she was fully dependent on staff for transfers and required two staff members to assist her safely.
The resident’s care plan was explicit on this point. An entry from over a year before the fall specified moderate to substantial assist with two staff members and a gait belt for all transfers due to increased weakness and behaviors. A later entry directed staff to use a full body mechanical lift with two-person assist for all transfers. These requirements were based on her assessed needs and known fall risk.
On the day of the fall, a single certified nursing aide attempted to transfer the resident from her bed to her wheelchair alone. The resident described what happened clearly when interviewed by investigators: the wheelchair was not positioned correctly, the aide grabbed her from under the arms and stood her up, and then let go of her on her left side. The resident said that is when she slid down to the floor. She was wearing her AFO brace at the time, and when she hit the floor she heard a cracking sound and told staff her leg hurt. She was hospitalized and diagnosed with a closed fracture of the left tibia and fibula.
When investigators interviewed staff, the failures ran deeper than a single aide’s decision. The nurse on duty at the time of the fall said she was unsure what the resident’s transfer status was. Another nurse stated she was not even aware the care plan required a two-person transfer. The Director of Nursing and the Administrator both confirmed that care plan interventions are expected to be followed by all staff — but the documented requirement had not been followed, and at least one nurse did not know it existed. The facility’s own fall prevention policy and transfer policy both required that transfer needs be documented in care plans and that staff follow those documented requirements. Neither happened on the day of the fall.
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.
