Failure to Provide Adequate Supervision and Use Gait Belt Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when facility staff failed to provide adequate assistance and supervision to prevent accidents for a newly admitted resident with multiple medical conditions, including right lung cancer, hypertension, and a post-surgical wound. The resident was assessed as needing staff assistance with transfers using a gait belt and a second person for hygiene and equipment management. However, the resident's care plan did not specify transfer or ambulatory status, nor did it address the use of a walker or gait belt, or the level of staff assistance required for mobility. On the day of the incident, a CNA assisted the resident from bed to a standing position without applying a gait belt, despite being trained and facility policy requiring its use. The resident began ambulating toward the restroom and reported feeling dizzy. The CNA instructed the resident to hold onto the grab bar and left the resident unattended to retrieve a gait belt. While the CNA was away, the resident attempted to turn and sit on the toilet, lost balance, and fell, striking their head and sustaining a left hip fracture that required surgical intervention. Interviews with staff and a family member confirmed that the resident was left standing alone and that the fall could have been prevented if the resident had not been left unattended. Facility policies and staff interviews indicated that all staff are expected to use gait belts for transfers and ambulation and to remain with residents who require assistance. The failure to follow these protocols directly led to the resident's fall and injury.