F0689

G

Improper Repositioning Without Gait Belt Causes Humerus Fracture and Poor Pain Control

Olney, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to safely transfer and reposition a dependent resident in accordance with its own safe patient handling and gait belt policies. The resident had multiple serious diagnoses, including COPD, diabetes, CHF, small cell B lymphoma, and hypertension, and was assessed on admission as not independent in transfers or ambulation, not predictable or cooperative, unable to bear weight, and requiring a full-body mechanical lift for all transfers. A functional abilities assessment documented that sit-to-stand was not attempted due to medical or safety concerns and that bed mobility required substantial/maximal assistance. Nursing documentation described the resident as a “heavy 2 assist,” very weak, and incontinent, with an indwelling catheter and a stage 2 pressure sore.

On the day of the incident, family requested that staff pull the resident up in his recliner because he was sliding down. Two CNAs (V3 and V4) stood on either side of the recliner and, without using a gait belt, hooked their arms under the resident’s armpits and used their other hands to grab the resident’s waist/pants to lift and pull him up in the chair. During this maneuver, multiple witnesses, including family and staff, reported hearing three loud pops from the resident’s left arm, after which the resident stated that his arm was broken. The resident then had minimal movement below the elbow and was unable to move the arm above the elbow without serious pain. The facility’s Safe Patient Handling Policy required use of lift equipment and/or assist devices for residents who were totally dependent or required extensive assistance, and the DON stated that repositioning in a situation such as this required use of a gait belt. The Gait Belt Use Policy required gait belts when staff transfer weight-bearing residents or assist with walking, and the therapy director stated that current recommendations for a similar resident would be repositioning with a gait belt rather than lifting under the arms.

Following the incident, there were additional failures in timely assessment and pain management. CNA V3 immediately reported the event to the RN on duty (V5), who stated she would assess the resident after finishing a medication pass but then forgot, did not assess the resident, and did not report the incident to the oncoming nurse. V3 continued to check the arm every 10 minutes for swelling or bruising, but no nurse assessment occurred before shift change. The oncoming RN (V6) was informed by V3 about the popping noise and the resident’s pain and then assessed the resident, noting pain with movement and decreased range of motion but no swelling or bruising. A portable x-ray was ordered and later showed an acute proximal left humerus fracture suspected to be pathological. Family and staff reported that the resident experienced severe pain that evening and into the next morning, with family describing “horrible pain,” moaning, and screaming with repositioning. Initially, only Tylenol was administered despite reports of severe pain, and both night and day shift nurses (V7 and V8) described difficulty obtaining narcotic pain medication from the pharmacy and on-call physicians. The primary care physician later stated that, in the resident’s weakened state and without a gait belt, the repositioning most likely caused the fracture and that the facility could have done a better job of taking care of the resident.