Failure to Hold Gait Belt During Ambulation Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to implement a known safety intervention for a resident with multiple medical conditions, including type 2 diabetes, peripheral vascular disease, and an amputation. The resident required supervision and the use of a gait belt, walker, and one-person assistance for ambulation, as documented in the care plan. During an incident, a nursing assistant ambulated the resident using a gait belt and walker, with a wheelchair positioned behind, but did not hold onto the gait belt as required. The resident let go of the walker to scratch her nose and subsequently fell, resulting in a displaced fracture of the left proximal femur/hip that required surgical intervention. Interviews and documentation revealed that the nursing assistant was unaware that the gait belt should be held during ambulation, rather than simply placed on the resident. The physical therapist confirmed that staff are expected to hold the gait belt at all times when assisting residents who require help walking. The care plan and facility policy specified that staff must maintain an upward grasp on the gait belt throughout ambulation. The failure to follow these established procedures directly led to the resident's fall and injury.