Failure to Use Gait Belt During Ambulation Results in Resident Fall and Spinal Fractures
Penalty
Summary
A resident with a history of generalized muscle weakness and back pain, who required assistance from one staff member for ambulation using a rolling walker and gait belt, sustained a significant fall resulting in multiple spinal fractures. The incident occurred when the resident was being assisted from the toilet to the sink by a staff member, during which the resident caught their foot on the floor and fell, striking their head and back. Review of the care plan and facility policy indicated that a gait belt was required for ambulation assistance, and this was the standard practice for the resident. Interviews and documentation revealed that the staff member assisting the resident at the time of the fall did not apply the gait belt and did not provide physical support to the resident's trunk or limbs, despite being in close proximity. The staff member acknowledged this deviation from the care plan and standard safety procedures. As a result of this failure to follow established protocols, the resident experienced a severe decline, including multiple vertebral fractures and increased fear of movement.