Unsafe Wheelchair Transport Leading to Tibia Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide safe wheelchair transport and adequate supervision to prevent an accident for a resident with significant mobility and cognitive impairments. The resident had diagnoses including cerebral infarction, osteoporosis, muscle weakness, vascular dementia, and bilateral lower extremity range of motion impairment, and was dependent on staff for transfers and mobility. A quarterly MDS showed the resident was moderately cognitively impaired, used a manual wheelchair, and required staff assistance for all ADLs, with a care plan noting dependence for all ADLs and a pattern of often refusing to get out of bed. On the day of the incident, 15–20 family members arrived to celebrate the resident’s birthday and requested that she be transferred out of bed to a larger area because her room was too small to accommodate them. The resident initially refused to get out of bed but later agreed after continued encouragement from family and staff. Nurse #1 and Nurse #2 used a mechanical lift to transfer the resident from bed to her personal wheelchair. During this transfer, the resident complained of leg pain and was unable to bend her legs to place her feet on the wheelchair footrests due to stiffness and pain, resulting in her legs being extended straight out rather than supported on the footrests. Despite recognizing that the resident could not bend her legs and was complaining of pain, Nurse #1 proceeded to transport her in the wheelchair by asking the resident to hold her legs up while being pushed approximately 30 feet to the medication cart for pain medication. As Nurse #1 was approaching the medication cart, the resident yelled out about her leg; Nurse #1 then observed that the resident’s left leg had dropped down between the wheelchair footrests and become caught underneath the wheelchair. The resident was found to have swelling and severe pain in the left shin, and subsequent ED evaluation and x‑rays revealed an acute fracture of the left proximal tibia. Interviews with Nurse #1, the DON, the Medical Director, and the Former Administrator confirmed that transporting the resident in the wheelchair with her legs extended and not on the footrests was unsafe and that the positioning in the wheelchair contributed to the injury. Title: Unsafe Wheelchair Transport Leading to Tibia Fracture
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.