Failure to Implement Gait Belt Use and Wheelchair Footrest Safety
Penalty
Summary
The facility failed to ensure proper accident prevention measures were implemented for two residents. For one resident with a history of muscle weakness and a displaced intertrochanteric fracture of the left femur, a Physical Therapy Assistant (PTA) was observed assisting her to ambulate in the hallway without the use of a gait belt. Multiple staff interviews, including those with the Therapy Director, Certified Nurse Assistants, and the Director of Nursing, confirmed that facility policy and staff orientation require the use of a gait belt when assisting any resident with ambulation in the hallway, regardless of their independence in their room. The resident's care plan indicated a need for supervision and assistance with ambulation due to a history of falls and weakness, but the intervention was not followed during the observed event. In a separate incident, another resident with Alzheimer's disease, muscle weakness, and severe cognitive impairment was transported in a wheelchair by a Physical Therapist without footrests in place. The therapist was observed pushing the resident down the hallway, then leaving her unattended to retrieve the footrests, during which time the resident placed her feet on the floor. Staff interviews confirmed that the expectation is for footrests to be in place whenever a resident is transported in a wheelchair. Both incidents demonstrate a failure to follow established safety protocols for ambulation and wheelchair transport, as observed and confirmed by staff and record review.