Failure to Use Gait Belts and Follow Transfer Protocols Results in Resident Falls and Injury
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent avoidable accidents, specifically for two residents reviewed for quality of care. One resident, an elderly female with severe cognitive impairment, osteoporosis, muscle weakness, and a history of falls, was not transferred according to her therapy evaluation, which required a two-person assist and the use of a gait belt. Instead, a CNA assisted her alone and without a gait belt, resulting in a fall that led to a hip fracture. The care plan was not updated after a previous fall, and the therapy recommendation for a two-person transfer was not incorporated into the care plan or communicated effectively to staff. Additionally, post-fall assessments and documentation were incomplete, and pain and mobility changes were not promptly recognized or reported, delaying the identification of the fracture. Another resident, also with cognitive impairment and mobility issues, was assisted by a CMA during a transfer without the use of a gait belt, contrary to facility policy and training. This resident had a history of falls and was care planned for extensive assist with one-person physical assist, but the required safety device was not used during the observed transfer. Interviews with staff revealed that while they had received training on the use of gait belts and fall procedures, there was inconsistency in following these protocols, and some staff were not familiar with the specific care needs of the residents involved. Facility policies required comprehensive, person-centered care plans, regular updates following changes in condition, and the use of gait belts for transfers and ambulation assistance. However, the care plans were not consistently updated to reflect therapy recommendations, and staff did not always review or follow the electronic care plans prior to providing care. The lack of adherence to established procedures and failure to use required safety equipment directly contributed to the residents' falls and injuries. The deficiency was identified as Immediate Jeopardy due to the risk of serious harm and injury to residents.