Failure to Prevent Neglect During Wheelchair Transport Resulting in Fracture
Penalty
Summary
A resident was being transported in a wheelchair by an agency LPN after attending an outside activity. During the transport, the resident's legs were not placed on leg rests and were covered by a blanket, which prevented the LPN from seeing their position. The resident complained of pain in her left leg after stating that her leg got stuck. Initial x-rays taken the same day were negative for fracture, but the resident continued to experience pain, swelling, and discomfort in her left ankle over the following days. Despite ongoing complaints and visible symptoms, it was not until a repeat x-ray several days later that an acute fracture of the distal left tibia and fibula was identified. The facility's investigation revealed that the LPN was unaware of the policy requiring the use of leg rests for residents unable to self-propel during wheelchair transport. The lack of adherence to this policy resulted in the resident's legs not being properly supported, leading to the incident and subsequent injury. The deficiency was identified as a failure to protect the resident from neglect by not providing necessary services to prevent physical harm.