Failure to Use Gait Belt During Ambulation Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to use a transfer (gait) belt during ambulation for a resident identified as being at risk for falls. The resident, who was blind and had diagnoses including type 2 diabetes and hypertension, required partial to moderate assistance for walking and was care planned for contact guard assist (CGA) or stand by assist (SBA) with one staff for all mobility. Documentation and care plans indicated that a gait belt was to be used during ambulation, particularly when walking to dine. On the day of the incident, the resident was ambulating in a hallway with a cane and a nursing assistant providing SBA. The resident lost balance and fell, landing on her left side and sustaining a left arm fracture. Multiple staff interviews and a review of surveillance video confirmed that the resident was not wearing a gait belt and the nursing assistant was not in close proximity at the time of the fall, contrary to care plan directives and facility expectations. Staff interviews revealed confusion regarding the meaning of CGA and SBA, and it was acknowledged that a gait belt should have been used for safety. The facility's fall prevention policy outlined universal fall precautions and the need for individualized care plans for residents at risk of falls, but did not specifically direct staff to use a gait belt with all transfers or ambulation. The lack of adherence to the care plan and failure to use a gait belt directly contributed to the resident's fall and subsequent injury.