F0689

G

Resident Fracture Due to Wheelchair Transport Without Leg Rests

Chicago, Illinois Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s safety and adequate supervision during wheelchair transport, specifically by transporting the resident without leg rests, resulting in a left leg fracture. The resident had diagnoses including other specified disorders of muscle, right-sided sciatica, unilateral primary osteoarthritis of the right knee, and age-related osteoporosis without current pathological fracture, with documented limitations in mobility and a care plan focus on gait abnormalities and fall risk. The resident’s MDS showed intact cognition (BIMS score 15), and the care plan noted she was able to self-propel short distances in the hall without leg rests, but also identified her as chair-bound on the fall risk assessment. Therapy orders for both PT and OT included wheelchair management and training.

On the day of the incident, CNAs transferred the resident from bed to a wheelchair via mechanical lift, and the wheelchair leg rests were not applied. The leg rests were reportedly on the resident’s table. The occupational therapist arrived to take the resident to therapy, did not apply the leg rests, and instructed the resident to hold her legs up while being pushed in the hallway. While being pushed, the resident’s left leg dropped and rolled or flexed backward under the wheelchair, and she heard and reported a popping sound. The resident yelled for the therapist to stop, stating that her leg was under the wheelchair and that her leg was broken. The therapist then stopped, returned to the room to retrieve and apply the leg rests, and continued to transport the resident down the hallway.

The therapist informed the physician at the nursing station, who assessed the resident’s leg, noted pain on palpation and with testing, and ordered x‑rays and limited weight bearing of the left lower extremity. The resident reported severe pain (9/10) and remained in the wheelchair until CNAs later transferred her back to bed via mechanical lift. The resident and her family declined x‑rays at the facility and requested transfer to the hospital emergency room, where she was diagnosed with a closed nondisplaced fracture of the medial malleolus of the left tibia. Interviews with the resident and her family member consistently described that the leg rests were not on the wheelchair at the time of the incident and that the therapist continued to attempt therapy despite the resident’s pain.

Multiple staff interviews revealed inconsistent understanding and practices regarding leg rest use and documentation. CNAs and nurses stated that residents who cannot self-propel or cannot move their legs require leg rests to prevent injury, and that leg rests should be applied when residents are transferred to wheelchairs and transported. The restorative director stated that the resident was capable of self-propelling and did not require leg rests before or after the incident, yet the restorative log she developed documented that the resident required a wheelchair with leg rests. The DON acknowledged that if a resident requires leg rests out of necessity and they are not used, an accident can happen, and described that staff might push residents with legs held up rather than using leg rests. The administrator and DON both stated there was no facility policy for Accident/Hazards/Supervision or wheelchair use, and the administrator confirmed that incidents are handled on a case-by-case basis without a specific policy, while also confirming there was no video footage available for review of the incident.

Staff interviews further showed confusion about whether physician orders were required for leg rests or self-propelling and indicated reliance on restorative logs and in-services for guidance. One LPN reported being told by the therapist that the resident’s leg had dropped and twisted while being transported and that leg rests were on at the time she was notified, while the resident and other staff stated leg rests were not applied at the time of the incident. Another CNA stated that everyone knew the resident required leg rests because she could not move her legs and recalled an in-service to apply leg rests as soon as residents were placed in wheelchairs. Overall, the documented events and interviews show that the resident was transported in a wheelchair without leg rests, contrary to staff statements about safe practice and restorative documentation, and that this failure resulted in the resident sustaining a left leg fracture.