F0689

G

Failure to Follow Assessed Transport Needs and Use Wheelchair Leg Rests

Hagerstown, Maryland Survey Completed on 03-06-2026

Penalty

Fine: $15,935

Summary

The deficiency involved the facility’s failure to ensure safe transport practices and adherence to a resident’s assessed transportation needs. A cognitively intact resident who used a wheelchair for mobility and was dependent for toileting and dressing was normally assessed to require stretcher transport due to limited leg mobility. On the day of the incident, the resident was transported off campus in a wheelchair without leg rests, despite the resident’s usual need for stretcher transport and inability to lift or maintain leg position. Shortly after transport began, the resident’s left foot became caught under the wheelchair frame, and the resident reported immediate pain. The resident stated that the GNA appeared to be in a hurry, did not use leg rests, and did not initially assess for injury when the resident yelled to stop.

The GNA later acknowledged that leg rests should have been used because the resident could not self-propel and reported asking the resident to hold their legs up while pushing the wheelchair a short distance before the resident yelled out. Another staff member subsequently attached the leg rests, and the resident was transported to the appointment without further assessment at that time. The resident reported increasing pain throughout the day. Diagnostic imaging on subsequent dates showed chronic fractures with a possible acute femur fracture and later confirmed a nondisplaced femoral condyle fracture, and medical orders were initiated for a left knee immobilizer every shift. The DON stated that residents transported in wheelchairs must have leg rests unless they refuse, that this resident was normally transported via stretcher, and that the GNA should have known this by reviewing the Kardex.