Failure to Provide Proper Foot Support During Wheelchair Transport Resulting in Fracture
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including multiple sclerosis, spastic hemiplegia, paraplegia, prior femur fractures, diabetes, and dementia, was transported in a wheelchair without proper foot support. The resident required extensive assistance with activities of daily living and was dependent on staff for lower body mobility and transfers. During transport from the therapy room to the resident's room, only one footrest was attached to the wheelchair, leaving the resident's left leg unsupported. As a result of the missing footrest, the resident's left leg was abruptly placed on the floor and became caught under the wheelchair, leading to an acute nondisplaced fracture of the proximal left tibia. Staff reported that they were unable to locate the second footrest but proceeded with the transport regardless, which directly resulted in the injury. The incident was confirmed through staff interviews, medical record review, and diagnostic imaging.