F0689

G

Failure to Use Wheelchair Footrests During Transport Resulting in Ankle Fracture

Middletown, Pennsylvania Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement care-planned safety interventions for a resident during wheelchair transport, resulting in an ankle fracture. The resident had diagnoses including chronic atrial fibrillation and diabetes, and a care plan identifying an ADL self-care deficit related to impaired cognition, muscle weakness, and decreased mobility. The care plan specified that the resident required assistance of one staff for locomotion in a wheelchair and that staff should ensure the resident’s feet sat comfortably on the footrests. A separate fall-risk care plan intervention directed that when the resident was being pushed in the wheelchair, footrests must be in place, and removed only when the resident was self-propelling.

On the day of the incident, the resident returned from a leave of absence and was being pushed down the hallway in a wheelchair by an outside transport company. The resident did not have footrests on the wheelchair when leaving or returning to the facility. While being pushed, the resident dropped her right foot, which went under the wheelchair, and she was heard calling out. Initially, no redness or swelling was noted, but later that day the resident complained of right ankle pain, with swelling and redness observed, and the ankle was wrapped and iced. There was no evidence the physician was notified at that time. Overnight, the resident continued to complain of right ankle pain, with warmth, swelling, and sensitivity noted, and an NP ordered an x-ray. The x-ray showed a right bimalleolar ankle fracture, and the physician was later notified and arranged further evaluation, which led to hospitalization and surgery for the fracture. The DON confirmed that the resident broke her ankle due to not having footrests on her wheelchair during transport.