Failure to Follow Care Plan and Gait Belt Policy Results in Resident Fall
Penalty
Summary
Staff failed to follow the care plan for a resident identified as very high risk for falls, resulting in a fall incident. The resident, who had intact cognition and a history of frequent falls, required assistance with transfers and ambulation using a gait belt and walker, as documented in her care plan. During an incident, a CNA was assisting the resident to the shower room and let go of the gait belt to move a shower chair that was blocking access to the toilet. The resident attempted to follow the CNA, lost her balance, and fell, sustaining a skin tear on her left hand. The fall was witnessed by staff. Further observations revealed that staff did not consistently use gait belts during transfers and ambulation, as required by both the resident's care plan and facility policy. On a separate occasion, another CNA was observed assisting the same resident without a gait belt and acknowledged this was not in accordance with protocol. The facility's policy mandates the use of gait belts for residents who are unsteady or require assistance, and the Director of Nursing confirmed that gait belts should always be used for transfers and ambulation.