The Illinois Department of Health has cited and fined Aperion Care International when an occupational therapist transported a resident in a wheelchair without attaching the leg rests, causing the resident’s foot to drop and roll under the moving wheelchair, resulting in a fracture of the left ankle. The resident, who was cognitively intact, gave a detailed account of what happened to staff and investigators, and a family member reported that the occupational therapist later gave a conflicting account to the Director of Nursing.
The resident was a cognitively intact woman with diagnoses including sciatica, right knee osteoarthritis, muscle disorders, and osteoporosis. She had active physician orders for both physical and occupational therapy, including wheelchair management and training. Whether she was formally required to use leg rests at all times was a matter on which staff gave conflicting accounts — some said she could self-propel without them, while others said she could not move her legs and required them. What was not in dispute was this: on the day of the incident, a staff member was pushing her in the wheelchair, not the resident propelling herself. The Director of Nursing acknowledged that when staff are pushing a resident who cannot hold her legs up independently, leg rests are necessary to prevent injury.
On the morning of the incident, a certified nursing aide transferred the resident from her bed to her wheelchair via mechanical lift. The leg rests were on the resident’s table nearby. The occupational therapist arrived at the room to take the resident to therapy. According to both the resident and a certified nursing aide who was present, the therapist said he did not see the leg rests and told the resident to hold her legs up in a raised position. He then began pushing her down the hallway without attaching the leg rests.
The resident later described what happened in detail: the therapist “arrived at her room to wheel her to the physical therapy room; she asked him to apply her leg rests and he informed her to hold her legs up.” As he pushed her down the hallway, her left foot dropped and rolled under the wheelchair. She heard a popping sound and yelled at the therapist to stop. The therapist stopped the wheelchair, returned to her room to retrieve the leg rests, came back, and attached them. He then continued wheeling her down the hallway. When they reached the nursing station, the therapist whispered to the physician, who walked over and examined the resident’s leg. The physician ordered pain medication, an X-ray, and no weight bearing on the left leg.
Despite the resident telling the therapist she was in too much pain to participate in therapy, he continued to the therapy room and asked her to stand. She told him she could not. He then returned her to her room. The resident described being left in her wheelchair in pain, saying “the nurse did not come and assess her leg and she was experiencing pain of 9/10.” She called her granddaughter, who came to the facility and requested the resident be transferred to the emergency room. The resident and her family declined the facility’s X-ray and requested hospital evaluation instead. At the hospital, imaging confirmed a closed nondisplaced fracture of the medial malleolus of the left tibia — a fracture of the inner ankle bone.
The resident’s family member reported an additional concern: upon arriving at the facility, she overheard the therapist in the Director of Nursing’s office stating that the leg rests had been on at the time of the incident. Both the resident and the certified nursing aide present at the transfer stated clearly that the leg rests were not on. The therapist himself, when interviewed by investigators, confirmed he did not apply the leg rests before leaving the room and that he began pushing the resident with her legs raised from the floor.
Every staff member interviewed agreed on the purpose of leg rests: to prevent injury and keep residents safe when they lack the strength or ability to hold their legs up while being transported. A certified nursing aide stated that “residents should have their leg rests applied to their wheelchairs during transferring around the facility” and that “the purpose of the leg rests is to prevent a resident from falling or getting injured.” The Director of Nursing acknowledged that if a resident requires leg rests and they are not used, an accident can happen, and that a resident’s leg can become caught in the wheelchair wheel if it drops. Despite all of this, the facility had no wheelchair policy and no accident or supervision policy in place at the time of the incident, a fact confirmed by the Administrator.
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.
