F0689

D

Failure to Use Safe Transfer Techniques and Wheelchair Footrests Resulting in Femur Fracture Concern

Saint Louis, Missouri Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe transfers and prevent accident hazards for a cognitively impaired resident with a history of knee replacement and hardware in the distal femur. The resident’s quarterly MDS showed severe cognitive impairment, dependence on staff for most ADLs, use of a wheelchair for mobility, and a need for substantial/maximal assistance with most transfers, including sit-to-stand and chair/bed transfers. The care plan identified a problem of falls and unsteady gait and directed staff to transfer the resident with a gait belt and assist of one staff. As early as 1/28, a CNA reported that the resident was complaining of leg pain, screaming, and holding or pointing to the leg, and noted the leg appeared slanted. The CNA reported these symptoms to the nurse on duty and a PT was consulted, who observed the resident yell out when the leg was moved and then provided elevating leg rests; however, there was no documentation in the medical record that the resident was assessed for injury at that time.

Over the following days, multiple CNAs noted the resident’s complaints of pain and resistance to movement. One CNA reported that on 1/31 the resident said “ow” and did not like the leg moved, and that this was reported to the charge nurse, who said they would check on the resident. Another CNA stated that the resident’s leg pain continued into the next week, with the resident screaming louder and with more swelling by the time of the next shift worked. Despite these ongoing complaints and observable changes, the resident continued to be moved and transferred, including by staff who sometimes picked the resident up and placed the resident in a recliner, and by staff who believed the resident could be a 1–2 person assist, even though the resident was supposed to be a Hoyer lift transfer. The medical record did not contain documentation of a fall in the month prior to the acute evaluation, and there was no documented nursing assessment of the leg after the initial complaints on 1/28.

On 2/1, the resident was observed being propelled in a wheelchair without foot pedals by a CNA. The resident screamed while being pushed down the hallway, and an LPN responding to the scream noted that the wheelchair had no foot pedals and that the resident’s right leg was dragging. The LPN observed some swelling and that the resident screamed when the leg was first touched, then laughed and denied further pain after the foot pedals were applied. The resident was then taken to meals and remained in the wheelchair. Later that day, the resident’s family member, who acknowledged that the resident required a two-person Hoyer lift, independently attempted to transfer the resident using a gait belt and then participated with staff in a stand-pivot transfer from wheelchair to bed without using a mechanical lift. During this transfer, the family member grabbed the resident’s ankles and lifted the legs into bed, and the resident expressed discomfort. Subsequent provider evaluation and x-ray revealed an age-indeterminate distal femur fracture around the area of the existing hardware, with severe pain, swelling, and deformity of the right knee noted, and the resident was sent to the emergency room for further evaluation and treatment. The facility later identified the lack of foot pedals during wheelchair propulsion and the improper transfer without a Hoyer lift as contributing factors to the incident.