The Illinois Department Of Health has cited and fined Manor Court Of Freeport when a staff member attempted to transfer a weakened resident alone using a manual stand aid device, despite the resident lacking the strength to use it safely and facility guidelines requiring two-person assistance. As a result, the resident fell during the transfer and suffered multiple fractures in his arm and elbow, leading to the facility finally changing his care plan to require a full mechanical lift with two staff members – the level of assistance he should have had from the beginning.
The resident in question had been steadily declining in health and required substantial assistance with all movements.
On the day of the incident, at around 5:45 AM, a nursing assistant attempted to transfer the resident from his bed to a wheelchair using a manual stand aid – a device that requires residents to be able to support their own weight and follow directions. According to the nursing assistant’s account, “as the resident was starting to stand up further and she was trying to put the seat flap down behind him, the resident’s legs gave out and he started to fall.”
Several concerning issues emerged about this transfer:
– The aide was working alone, though other staff stated “the resident has not been a one person assist for months”
– No gait belt was used for safety
– Staff had been transferring the resident inconsistently – as his wife noted, “some of the staff would use a gait belt, and some wouldn’t… some staff would just grab the resident by the back of his pants to assist him up”
– Multiple staff members indicated the resident wasn’t strong enough for the manual stand aid and should have been using an electric lift
The manufacturer’s manual specifically warned that to use the stand aid, a resident “must have enough leg and lower body strength to stand up and remain in the standing/sitting position.” For residents lacking this strength, “a sit-to-stand lift such as the electric powered patient lift is preferred and recommended.”
The Director of Nursing later acknowledged the error, stating, “The resident needs to be able to grab onto the bar and bear his own weight to use the stand aid. It was never brought to my attention that they were struggling or were needing assistance with his transfers.” The Nurse Practitioner added that “the resident had been experiencing a steady decline in health and his transfer status should have been reassessed.”
As a result of this improper transfer, the resident suffered multiple serious injuries:
– A comminuted (broken into multiple pieces) fracture of his upper arm
– A fractured elbow
– Significant soft tissue swelling and bruising
After the incident, the facility finally changed the resident’s care plan to require a “full mechanical lift with staff assist of two” – the level of assistance he should have had before the injury occurred.
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 Chicago 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.
