Failure to Provide Required Staff Assistance During Resident Ambulation
Penalty
Summary
A deficiency occurred when a resident, who was at risk for falls due to limited physical mobility, chronic pain syndrome, and osteoarthritis, was not provided with the required one staff assistance during ambulation. The resident's care plan specified the need for one staff assist with a gait belt and walker for transfers. On the day of the incident, a Certified Nursing Assistant (CNA) assisted the resident off the toilet, cleaned the resident, and provided the walker. The CNA then positioned themselves in front of the resident, near the bathroom door, rather than at the resident's side or behind, and allowed the resident to ambulate independently. As the resident attempted to walk toward the CNA, the resident fell backwards, resulting in multiple injuries including a hematoma, bruises, and skin tears. Interviews with facility staff confirmed that the CNA did not follow the proper procedure for assisting a resident who requires one staff assist with a gait belt and walker. The CNA was not in a position to provide support or assist in lowering the resident to the floor if needed, as required by the resident's care plan and standard practice. The incident was witnessed and documented by staff, and the resident was assessed for injuries following the fall.