The Illinois Department of Health has cited and fined Bethany Rehab & Health Care Center when a staff member failed to properly assist a resident during a transfer from wheelchair to bed, resulting in a fall that caused multiple fractures to the resident’s knee and changed her mobility status.
The resident in question had been admitted just days earlier, a woman with a history of falls and notable weakness, particularly in her legs. Despite these challenges, she maintained her cognitive sharpness—alert, aware, and able to advocate for herself.
On the night of the incident, the resident had stayed up later than usual. “I should not have stayed up so late,” she would later recall. As the hour grew late, she needed to get into bed. According to the resident’s assessment, she required maximum assistance for mobility and transfers due to the weakness in her knees. Her care plan specifically indicated she needed significant help to move from sitting to standing positions.
A young Certified Nursing Assistant (CNA) entered the room to help with the bedtime routine. What happened next would become a matter of conflicting accounts.
The resident’s story was clear and unwavering: “While transferring myself into bed, my knees gave out and I fell forward onto my knees,” she explained. “The CNA was in the room but was just standing there and did not help me in any way.” According to the resident, no safety belt was used, and no proper assistance was provided.
The CNA, however, told a different tale. “I was advised by other aides to transfer the resident with a gait belt, and she was a one-person assist,” the aide insisted. “I had the gait belt around her and was transferring her from the wheelchair to the bed. During the transfer, the resident did not want to stand up so I was standing behind her holding onto the gait belt and helped her stand up, then moved the wheelchair out of the way. As she was pivoting her knees gave out and I lowered her to the ground on her buttocks.”
The nurse who responded to the scene added another perspective. Upon entering the room with the CNA, she found the resident sitting on the floor, alert and oriented. Notably, the nurse “did not recall seeing the gait belt around the resident” when she entered the room. Only after the assessment did she observe the CNA place a gait belt around the resident to help get her into bed.
Initially, there appeared to be no injury. The resident had no complaints of pain at the time. But days later, when the resident returned from a scheduled orthopedics appointment for an unrelated matter, she mentioned right knee pain. A diagnostic scan revealed the hidden damage: a fracture to the right knee.
Further imaging confirmed “age-indeterminate fractures of the distal femur just proximal to the knee prosthesis and at the superior aspect of the patella (kneecap).” The report specifically noted that these injuries “correlate with timing of trauma and pain”—connecting them directly to the fall incident.
The Director of Nursing at the facility was forthright in her assessment of the situation. After speaking with the resident and reviewing the evidence, she stated she “did believe the resident, and the transfer occurred without a gait belt, resulting in the resident falling and fracturing her leg.” She found the CNA’s statement “to be untruthful regarding the events that took place.”
The consequences for the resident were significant. Because of the fracture, she became non-weight bearing and required a mechanical lift for all transfers—a much more restrictive intervention than her previous level of care. When asked about the facility’s policy on gait belt transfers, the Director of Nursing admitted there was no formal policy, saying only that “the facility follows best practice when doing gait belt transfers.”
As the resident sat in her wheelchair weeks later, now wearing a brace on her right leg and with a mechanical lift sling positioned beneath her, the lasting impact of that night’s events was evident. A preventable accident had resulted in increased dependency and a painful fracture—all because proper transfer techniques and safety precautions weren’t followed.
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.
