Failure to Maintain Gait Belt Use During Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to properly utilize an assistive device, specifically a gait belt, during a staff-assisted transfer of a resident. The resident, who had a history of right femur fracture, cognitive impairments, gait and balance problems, deconditioning, and parkinsonism affecting balance and mobility, was care planned to require assistance from one staff member with a gait belt for transfers. During a transfer from the bathroom to the sink, the CNA assisting the resident let go of the gait belt to throw away trash, leaving the resident unsupported. At that moment, another staff member observed the resident begin to tip backward and attempted to alert the CNA. The resident subsequently fell backward, struck her head on the sink, and fell to the ground. As a result, the resident complained of pain, was sent to the emergency room, and was diagnosed with a displaced right femur fracture requiring surgical repair. The failure to maintain hold of the gait belt during the transfer directly led to the resident's fall and injury.