The Illinois Department of Health has cited and fined Montgomery Place, a nursing home in Chicago when, according to state investigators and facility records, a certified nursing aide performed a sit-to-stand mechanical lift transfer alone — without a second staff member present despite the resident being assessed as dependent for transfers requiring two or more helpers — and the 96-year-old resident slid off the bed during the transfer with her legs becoming tangled underneath her, resulting in a right femoral fracture. The resident, who was fully dependent on staff for transfers, was hospitalized following the incident.
The resident had been at the facility for over a year, originally admitted following a fall that resulted in a tibia and fibula fracture. She had a long medical history that included a prior history of falls, generalized muscle weakness, spinal stenosis, polyosteoarthritis, and reduced mobility. Her most recent assessment classified her as dependent for transfers — meaning, per the assessment definition, the assistance of two or more helpers was required. Her fall risk evaluation classified her as high risk for falls. Multiple staff members confirmed she had poor trunk control, could not sit up unassisted for long, and could not bear weight on her legs.
On the morning of the incident, a certified nursing aide working the overnight shift was transferring the resident from her bed to her wheelchair using a sit-to-stand mechanical lift. According to the aide’s own account, she had properly applied the lift’s belt and sling, positioned the resident’s feet on the base, and pressed the up button. As the resident began to lift off the bed, she jerked forward. The aide attempted to lower her back down, but during this process the resident’s buttocks slid off the bed, and her right foot came off the lift’s foot base. The aide lowered the resident toward the floor. By the time the lift had lowered, the resident’s right leg had bent inward and was twisted underneath her body. She came to rest in a seated position on the floor with her right leg folded beneath her.
The aide left the room to find another certified nursing aide to help her. When they returned, they got on either side of the resident and lifted her back into bed. The resident was screaming in pain and complaining repeatedly about her foot, her knee, and her leg. The nurse coming on duty was notified, the resident’s physician was called, and the resident was sent to the hospital by ambulance. The hospital diagnosed her with a right periprosthetic femoral shaft fracture — a fracture of the thigh bone at the site of her artificial knee joint.
Investigators also learned that the aide routinely transferred the resident alone using the sit-to-stand lift. The aide who performed the transfer told investigators that while staff are instructed to use mechanical lifts with two people, she had been using the sit-to-stand on her own because people were not always available to help her, and she had never had a problem doing it on her own before. The second aide who came to help after the fall confirmed in her own interview that this aide routinely got the resident up out of bed by herself using the sit-to-stand lift, stating she knew this because she had never been asked to help with that resident’s transfers.
Multiple staff members agreed the injury may have been prevented if a second person had been present. The aide who performed the transfer told investigators directly: “If there were two CNAs there that morning, it could have prevented the resident from getting injured. Two CNAs could have prevented her from sliding off the bed and with two people we would have been able to get her back onto the bed instead of having to lower her to the floor.” The Director of Nursing acknowledged that under the assessment definition of dependent — which means the resident requires the assistance of two or more helpers — the resident should have had at least two staff members assisting with the sit-to-stand lift. The therapy director, the medical director, the registered nurse, and the Director of Nursing all stated that two staff members should assist during mechanical lift transfers for safety.
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.
