IDPH has cited and fined St. Paul’s Senior Community when a staff member transferred a resident by herself in violation of the care plan that called for a sit to stand transfer with the assistance of 2 staff members. The failure resulted in the resident sustaining bilateral femur (thigh) fractures which ultimately contributed to her death three days later.
A sit-to-stand lift is a type of lift commonly used in nursing homes. This type of lift should be used only with residents who have some ability to bear weight and who are cognitively intact enough to follow instructions from staff. As with Hoyer lifts, this lift requires the assistance of two staff members to use it safely – one to operate the controls of the lift, the other to assure the safety of the resident.
The resident in question had a care plan that documented “TRANSFER: sit to stand using 2 assist.” However a Certified Nurse’s Aide (CNA) stated that she had been transferring the resident by herself for a while, despite the resident normally requiring a 2-person assist. The CNA admitted that she “lifted her (the resident) with a gait belt and put her own leg between the resident’s legs.” She stated that she (the CNA) “stumbled and the resident fell on top of her.”
A Licensed Practical Nurse (LPN) heard yelling and found the resident with one knee on the floor and the CNA holding the resident up against the dresser. The LPN assessed the resident and noticed a bulging area on her right thigh. Instead of waiting for a mobile x-ray, the LPN called an ambulance to transport the resident to the hospital for a quicker x-ray and additional pain management.
Importantly, the LPN stated that she did not see a gait belt or a sit to stand in the room. She further stated that the CNA never asked her or the other CNA on the unit for help to transfer the resident.
The hospital’s radiology report documented “Acute significantly displaced and comminuted fracture of the mid left femur. Acute significant fracture of the mid right femur.” The resident passed away a few days after the incident.
The Medical Director said that “in his professional opinion the bilateral femur fractures contributed to R2’s death.”
The ER Physician stated that the resident had very severe osteopenia and never would have survived surgery. He further stated that he is unsure if the fractures contributed to her death, but it did not help.
In Summary, the facility failed to ensure the resident’s safe handling during a transfer, ultimately leading to the resident’s significant injury and contributing to the resident’s death a few days later.
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.
