The Illinois Department of Health has cited and fined Evercare at Edwardsville when two residents were injured during transfers — one because a certified nursing aide transferred her without the required gait belt, causing her to fall and fracture her left upper arm, and a second because a mechanical lift sling hook was not properly secured, causing the resident to slip out and strike her head. Both injuries were preventable and both violated the facility’s own transfer policies.
The first resident had a below-the-knee amputation on her left leg and significant weakness, making proper transfer technique critically important. Her care plan required extensive assistance for transfers due to her weakness and impaired mobility. During a transfer from wheelchair to bed, the resident shifted her weight to her left side — the side with the amputation — lost her balance, and fell. The certified nursing aide who was performing the transfer stated she had been told by other aides that this resident preferred a “bear hug” transfer method, and on that basis she was not using a gait belt. The resident sustained a fracture of the left humeral neck and was sent to the emergency room. The facility’s transfer policy states explicitly that use of a gait belt for all physical assist transfers is mandatory. The Administrator confirmed she would expect staff to follow that policy.
The second resident had Alzheimer’s disease, muscle weakness, and was fully dependent on staff for all transfers. Her care plan required a full mechanical lift with two staff members for all transfers. On the morning of the incident, the certified nursing aide on duty stated the facility was extremely short-staffed and that she asked multiple staff members to help her with the mechanical lift transfer and no one would assist her. She proceeded to perform the transfer alone. While lifting the resident, the sling hook came unhooked, and the resident slipped out of the sling and struck her head on the floor. The resident sustained a hematoma to the back of her head, complained that her head hurt, and was transported to the emergency room by ambulance. The hospital noted the resident had fallen approximately four feet. The Director of Nursing confirmed the hook was not completely secured before the lift began and that the staff member was performing the transfer by herself — in direct violation of the care plan requirement for two-person assist.
Taken together, both incidents reflect the same core failure: staff did not follow documented transfer requirements, and residents were seriously hurt as a result. The facility’s own policies required mandatory gait belt use for all physical assist transfers and two-person mechanical lift transfers for residents who cannot be safely transferred otherwise. In one case a staff member substituted an informal technique based on secondhand advice from colleagues. In the other, a staff member proceeded with a high-risk transfer alone after being unable to find a second person to assist her.
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.
