Failure to Follow Ambulation Policy Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's ambulation policy and procedure for a resident with a history of falls, abnormal gait, osteoporosis, and moderately impaired cognition. The resident required moderate assistance with walking and was identified as being at risk for falls. On the day of the incident, the resident attempted to get out of bed to use the restroom, and a CNA, who was monitoring the resident, approached to assist. Instead of following the policy, which required staff to stand on the resident's weakest side and slightly behind during ambulation, the CNA walked in front of the resident while leading her to the restroom. The CNA stated that the resident did not like to be touched or held, and as the CNA reached for the restroom door, the resident lost her balance and fell. Because the CNA was in front, she was unable to catch the resident or prevent the fall. As a result of the fall, the resident sustained a laceration above the right eyebrow, requiring transfer to an acute care hospital for evaluation and sutures. The facility's Director of Rehab and Director of Nursing confirmed that the staff member should have walked next to or slightly behind the resident to provide proper supervision and assistance, as outlined in the facility's ambulation policy.