Failure to Use Gait Belt Results in Resident Fall and Fracture
Penalty
Summary
Staff failed to apply a gait belt while assisting a high fall-risk resident during ambulation after toileting. The resident, an alert and oriented female with a history of multiple falls, impaired mobility, and balance problems, was being assisted by a CNA when she became weak and fell while attempting to move from the bathroom to her recliner. The resident was not wearing a gait belt at the time of the fall, as confirmed by multiple staff interviews and direct observation after the incident. The resident sustained a left femur fracture requiring surgical repair as a result of the fall. The resident's care plan and fall risk assessment indicated she required one-person assistance, a gait belt, and a walker for transfers and ambulation due to her unsteady gait and high risk for falls. Staff interviews confirmed that the use of a gait belt was standard practice for this resident, but it was not in use at the time of the incident. The facility's fall program policy required evaluation and implementation of interventions for residents at risk for falls, but these interventions were not followed during the incident, directly leading to the resident's injury.