Failure to Use Gait Belt During Resident Transfer and Ambulation
Penalty
Summary
A resident with a history of ovarian cancer and a recent fracture, who was independent with transfers and ambulation using a walker, experienced a change in status with increased confusion and weakness. On the morning in question, the resident had an unwitnessed fall in the bathroom and was subsequently identified as high risk for falls. Despite this change in condition and the facility's policy requiring the use of gait belts for residents needing assistance with ambulation or transfers, staff failed to use a gait belt when assisting the resident later that morning. During this assistance, the staff member momentarily let go of the resident to adjust a chair cushion, resulting in the resident falling backwards. Interviews with staff confirmed that the resident was more confused and weak than usual, and that the need for close monitoring and use of a gait belt had been communicated. However, the staff member assisting the resident did not use a gait belt and instead held onto the back of the resident's pants. The facility's policy, last reviewed in September 2024, clearly stated that gait belts should be used for any resident requiring assistance with ambulation or transfers, but this protocol was not followed, directly contributing to the resident's second fall.