Failure to Use Gait Belt and Investigate Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to safely transfer a resident, resulting in a fall, and did not conduct a thorough investigation of the incident. The resident, who was cognitively intact and required partial to moderate staff assistance for chair/bed transfers, had a documented history of two or more falls without injury. The resident's care plan and functional mobility assessment specified the use of a gait belt and one-person assist for transfers, along with the use of grab bars or a walker. During the incident, the resident was being assisted into bed from a wheelchair by a CNA, who did not use a gait belt as required. The resident let go of the bed rail to adjust his pants, lost balance, and was assisted to the floor, sustaining no injuries. Following the fall, there was no documentation of a thorough investigation. The nursing note recorded the fall, but an incident report and a fall investigation packet were not completed. The CNA involved confirmed that a gait belt was not used during the transfer, despite the resident's care plan and assessment indicating its necessity. The facility's policy on managing falls requires staff to implement and monitor individualized fall prevention interventions and to re-evaluate interventions if falls continue, but there was no evidence that these procedures were followed in this case.