Failure to Implement Care Plan Interventions During Ambulation
Penalty
Summary
A deficiency occurred when staff failed to implement care plan interventions for a resident with severe cognitive impairment, Parkinson's Disease, and dementia. The resident's care plan required ambulation with contact guard, use of a gait belt, and a wheeled walker for safety. On the day of the incident, the resident was observed ambulating without the walker and without a gait belt. Although staff intervened and provided supervision, the resident continued to ambulate without the required gait belt and at times refused to use the walker. Despite being positioned next to the resident, staff were unable to prevent a fall when the resident lost balance and fell after standing up and walking away from the nurse station. The resident sustained a left hip fracture as a result of the fall and required hospital admission. Interviews with staff confirmed that the gait belt, a required intervention per the care plan and facility policy, was not used at the time of the fall. The facility's policy mandates the use of gait belts for all transfers and assisted ambulation according to assessed needs and care plans. The failure to follow these interventions directly contributed to the resident's fall and subsequent injury.