Failure to Provide Required Assistance and Use Gait Belt During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to provide required assistance and utilize a gait belt during a toilet transfer for a resident identified as needing moderate assistance. The resident, who had a history of falls, muscle weakness, and multiple orthopedic conditions, was documented as high risk for falls and required one-person assistance for transfers according to the care plan and staff assignment sheet. On the day of the incident, a CNA assisted the resident out of bed and provided a walker but did not remain with the resident during ambulation, instead stepping into the bathroom to retrieve gloves. The CNA also did not use a gait belt during the transfer or ambulation, contrary to facility policy and the resident's care plan. As a result, the resident lost balance while walking unassisted to the bathroom, fell backward, and sustained multiple serious injuries, including rib fractures, a lung laceration, and a large bruise. The incident was confirmed by interviews with the resident, CNA, and nursing staff, as well as review of the medical record and hospital report. Facility policy and recent fall prevention training both required the use of a gait belt during all transfers and ambulation, which was not followed in this case.