F0689

G

Failure to Use Wheelchair Foot Pedals Resulting in Hematoma and Ongoing Transport Hazards

Pueblo, Colorado Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to wheelchair transport without foot pedals. One resident on anticoagulant therapy, with diagnoses including atrial fibrillation, history of falling, unsteadiness on feet, and fragile skin, used a wheelchair for mobility and had a care plan goal to minimize abnormal bleeding and bruising. Despite this, the resident was transported in a wheelchair without foot pedals by the social services director (SSD) when being taken to an activity in the dining room.

During this transport, the resident’s foot dropped and her left leg hit the wheelchair. The SSD stopped, visually checked the leg, and did not see any marks, while the resident reported that her leg hurt but stated she still wanted to play bingo. The SSD then continued to assist the resident into the dining room and informed the nurse about the incident. Later that day, the resident complained of pain in the lower left leg and was given PRN pain medication. Subsequently, a large hematoma measuring approximately 8 inches by 4 inches was identified on the left calf, and the physician was notified, resulting in orders to hold the resident’s anticoagulant and to elevate and ice the leg. The resident was sent to the emergency room, where imaging showed soft tissue swelling without fracture, and she was treated and returned to the facility.

The resident’s records documented ongoing severe pain, a progressively enlarging hematoma, and repeated assessments and treatments, including a splint and additional pain medications. The hematoma was later documented as 10 inches by 6 inches, and the resident required a second transfer to the emergency room for further evaluation. The DON acknowledged that foot pedals were likely not in use at the time of the initial incident and that no root cause analysis was conducted. In addition to this resident’s case, surveyor observations on multiple occasions showed other residents being transported by various staff (including CNAs, the infection preventionist, and housekeeping staff) in wheelchairs without proper use of foot pedals, with residents’ feet dragging on the floor or positioned unsafely between or off the pedals, demonstrating a broader pattern of unsafe wheelchair transport practices contributing to the deficiency.

Staff interviews confirmed that they understood foot pedals were needed to prevent residents from bumping or dragging their feet or potentially falling, and that they had received education on this topic after a prior incident where a resident bumped a foot during wheelchair transport. Despite this knowledge, the observed practice during the survey period showed continued nonuse or improper use of wheelchair foot pedals when residents were being pushed, including residents lifting their feet to avoid dragging due to missing or flipped-up pedals. This pattern of actions and inactions—transporting a resident on anticoagulants without foot pedals leading to a significant hematoma and ongoing observations of similar unsafe transport for other residents—formed the basis of the cited deficiency for failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent accidents.