The Illinois Department of Health has cited and fined Pearl of Orchard Valley in Aurora, Illinois when a resident fractured her right tibia and fibula after falling during a transfer that did not use the mechanical lift and two-person assistance her care required. State investigators determined the facility failed to ensure the appropriate lift equipment and staffing were used when the resident was weighed and transferred.
The resident, an 84-year-old woman, had diagnoses including a prior stroke, total occlusion of the arteries of her extremities, atherosclerosis of her left lower extremity, peripheral vascular disease, end-stage renal disease requiring dialysis, muscle disorders, unsteadiness on her feet, dementia, an anxiety disorder, neuropathy, and a history of falls. A standardized assessment on file before the incident found she was severely cognitively impaired and totally dependent on staff for transfers between her bed and chair, and that she required substantial to maximal assistance with other daily activities due to impairment of both legs. Records show she had been formally assessed as requiring transfers using a total mechanical lift with two staff members assisting for a substantial period leading up to the incident.
On the day of the fall, the resident was being transferred from her wheelchair to a weighing scale ahead of a dialysis treatment. The facility’s incident report states that only one certified nursing assistant was performing the transfer. According to the CNA’s statement, she assisted the resident to stand by holding the waistband of her pants while the resident held onto the grab bar on the scale, and the resident’s legs suddenly gave way, causing her to fall to the floor.
The CNA stated she then called a nurse, and the two of them manually lifted the resident off the floor and back into her wheelchair before returning her to her room. The resident continued to complain of right leg pain and was sent to the hospital, where she was admitted and hospitalized for 10 days before returning to the facility. Hospital records confirmed the resident had sustained traumatic fractures of her right tibia and fibula.
The facility’s own incident report initially listed an incorrect date for the fall. The director of nursing stated this was a typographical error and confirmed the fall occurred during the resident’s early-morning transfer to a weighing scale before dialysis, as otherwise described in the report.
The CNA stated that although she had previously used the total mechanical lift to transfer the resident, another certified nursing assistant had told her the resident could be transferred manually without the lift. That certified nursing assistant stated it had been some time since he had cared for the resident, denied giving that instruction, and said the CNA who performed the transfer should have reviewed the resident’s care documentation to determine the appropriate transfer method.
The director of nursing stated that residents assessed as needing a total mechanical lift should have their weight obtained using the facility’s lift, which is equipped with a built-in scale, rather than a separate stand-up scale. When asked why that equipment was not used for the resident, the director of nursing said there was no explanation. The director of nursing also stated that the CNA involved in the transfer received disciplinary action, and that the nurse who helped lift the resident off the floor after the fall was terminated because the resident should not have been manually lifted from the floor following a fall.
The facility’s medical director, who also serves as the resident’s attending physician, stated he was informed that the resident had fallen and sustained fractures of her right tibia and fibula.
During an interview conducted after the fall, the resident — who was alert and responsive — stated that her legs had given way while she was being transferred to the scale, and that she experienced severe pain and was taken to the hospital. She said staff sometimes transferred her manually, sometimes with a mechanical lift, and sometimes with one or two staff members assisting. She reported ongoing pain in her right leg, which she rated an 8 out of 10.
The facility’s Safe Transfer Policy requires staff to use the appropriate mechanical lift device and provide two-person assistance for residents assessed as requiring a total mechanical lift for transfers.
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.
