Failure to Use Gait Belt Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and required assistance for transfers, experienced a fall resulting in a right proximal humerus fracture. The incident took place while the resident was being assisted from the bathroom to the bed by a nurse aide. The aide turned away to arrange bed linens, during which time the resident lost balance and fell backwards. Documentation and witness statements confirmed that a gait belt, which was required by the resident's care plan and facility policy for ambulation and transfers, was not used during this transfer. The nurse aide admitted to forgetting to use the gait belt, despite being aware of the policy. The facility's abuse and neglect policy mandates the use of appropriate safety measures to prevent harm, and defines neglect as the failure to provide necessary goods and services to avoid physical harm. The investigation substantiated that neglect occurred due to the failure to use a gait belt, directly leading to the resident's fall and subsequent injury. Clinical records indicated the resident required pain management and a sling for the shoulder fracture following the incident.