Failure to Follow Transfer Protocols and Use Gait Belt Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to follow established transfer protocols and policies for a resident who required assistance, resulting in a significant injury. Specifically, staff did not use a gait belt during a bed-to-wheelchair transfer and did not adhere to the identified mechanical lift transfer status for a resident recovering from a hip fracture. The resident, who had a recent decline in cognitive status and was identified as needing increased assistance, was transferred without the required equipment or support, leading to a fall and an acute right femoral fracture that required surgical intervention. Observations and interviews revealed that staff members were aware of the facility's policy requiring the use of gait belts for assisted transfers, and that all CNAs were issued gait belts and trained on their use. Despite this, the staff involved in the incident did not utilize a gait belt or mechanical lift as indicated in the resident's care plan and transfer status. The resident was left alone on the toilet without supervision, and during another transfer, was assisted by only one staff member without the appropriate safety equipment, contrary to the care plan and facility guidelines. Documentation review showed inconsistencies in the resident's fall risk assessments and care planning. The care plan did not specify the use of a gait belt or the required level of assistance prior to the incident, and the only fall risk evaluation available was completed on the day of the fall, identifying the resident as high risk. The facility's fall prevention program and employee handbook both require individualized assessment and the use of safety interventions, including gait belts, but these were not implemented as required for this resident.