Failure to Use Gait Belt During Resident Ambulation Results in Fall and Injury
Penalty
Summary
A certified nursing assistant (CNA) failed to use a gait belt while assisting a resident with ambulation to her room, contrary to the resident's care plan and facility policy. The resident, who was severely cognitively impaired and had multiple diagnoses including osteoporosis, dementia, and a history of fractures, lost her balance and fell backward. The CNA was unable to prevent the fall due to not using the required gait belt, resulting in the resident striking the back of her head. Following the fall, the resident was assessed and found to have a hematoma on the back of her head and was subsequently transferred to the emergency department. Further evaluation revealed a left femur fracture that required surgical intervention. The resident's care plan specifically indicated the need for one-person assistance with a gait belt and walker during ambulation, which was not followed at the time of the incident. Interviews with facility staff and review of records confirmed that the CNA had previously received training on safe resident handling and fall prevention, and that the facility's policy required the use of gait belts for ambulation and transfers. The director of nursing acknowledged prior discussions with the CNA regarding safety issues, including not following care plans and not using gait belts. Despite ongoing education and posted reminders, there was no formal documentation of staff education or audits to ensure compliance with gait belt use at the time of the incident.