The Illinois Department of Health has cited and fined The Loft Rehab of Peoria when staff failed to ensure required foot pedals were on a resident’s wheelchair during transport, resulting in the resident’s leg getting caught in the wheel. The incident caused a severe fracture requiring emergency surgery and hospitalization.
The resident in question was a 77-year-old woman with severe dementia who required total assistance from staff for transfers and wheelchair mobility. Her cognitive impairment was documented as severe, with assessment scores indicating she had extremely limited mental capacity and poor safety awareness.
The facility’s care plans specifically addressed the resident’s mobility needs and fall risks. Her wheelchair locomotion care plan clearly stated that she “requires total assist of one staff with wheelchair locomotion” and emphasized staff must “ensure foot pedals in place prior to propelling wheelchair.” Similarly, her fall prevention care plan reinforced this requirement, documenting that staff should “ensure foot pedals on wheelchair with locomotion.”
Despite these clear care plan requirements, the incident occurred when two nursing assistants were transporting the resident down a hallway. According to witness accounts, the resident was exhibiting behavioral symptoms, becoming agitated and resistant to being moved. One of the nursing assistants described the situation: “I was pushing the resident down the hallway to her room. The resident was sliding down in her wheelchair… was screaming at us. I kept telling the resident I was going to push her, and she needed to put her feet up so I could push her.”
The resident did not have her wheelchair foot pedals attached during this transport. As she became increasingly agitated, she began to slide forward in her wheelchair and attempted to put her feet down on the floor. Her left leg became caught in the wheelchair wheel during this process. A Licensed Practical Nurse who witnessed the incident stated: “The resident’s legs were crossed and the nursing assistant was pushing the resident down the hallway. The resident was having behaviors and did not have wheelchair pedals on her wheelchair… the resident’s left leg got caught in the wheel of the wheelchair.”
When the resident began to fall, a second nursing assistant attempted to help by cradling and lowering her gently to the floor. However, the resident’s left foot remained “bent under and caught in the wheelchair wheel” during this process, causing significant injury.
Initially, facility staff documented that the resident appeared to have no injuries from the incident. The post-fall evaluation completed immediately after the event noted “no injury at time of fall.” However, over the following days, it became clear that the resident had sustained serious damage.
The resident began exhibiting new behaviors, screaming out when touched, which staff noted was unusual for her. When she continued to show signs of severe pain, facility staff ordered emergency X-rays and eventually called 911 when her condition worsened. Hospital records documented that the resident “is clearly in a lot of pain” and was “unable to provide any further history due to dementia.”
Medical examination revealed the resident had suffered an “acute periprosthetic distal left femur fracture” – a serious break in her thigh bone near an existing prosthetic device. The injury required surgical intervention, with the resident undergoing “open reduction internal fixation” to repair the fracture. This type of surgery involves opening the leg and using metal hardware to hold the broken bone pieces in proper position for healing.
Multiple staff members interviewed during the investigation acknowledged that foot pedals were not in place during the incident. One nursing assistant stated: “I do not know why the pedals were not on the resident’s wheelchair.” Another admitted: “Sometimes the resident has wheelchair pedals and sometimes the resident does not have wheelchair pedals. I do not know why.”
The facility’s occupational therapist explained proper protocol, stating that “if a resident is having behaviors and putting their feet on the floor while staff are pushing the wheelchair, then the staff should stop pushing the resident because a fall could occur. They should place foot pedals on the wheelchair and monitor the resident’s behavior.”
Even after the incident, problems with foot pedal compliance continued. During the investigation, surveyors observed the resident in her wheelchair with only the left foot pedal attached while her right foot rested on the floor, demonstrating ongoing inconsistency in implementing the required safety measures.
The resident’s physician confirmed that proper use of foot pedals “could have potentially helped with preventing her fall or getting her leg caught in the wheel” if staff had followed the care plan requirements.
The incident represents a failure to follow established care plans designed to protect a vulnerable resident with severe cognitive impairment, resulting in an injury that caused significant pain and required major surgical intervention.
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.
Leave a Reply
You must be logged in to post a comment.