Failure to Use Gait Belt and Implement Fall Precautions During High-Risk Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer techniques and fall prevention measures for a resident with a known history of frequent falls and self-transferring. The resident had moderate cognitive impairment (BIMS 11), required partial assistance with transfers and sit-to-stand, was always incontinent of urine, and had multiple comorbidities including hypertension, diabetes mellitus, COPD, and morbid obesity. Her care plan identified self-care deficits, impaired balance, poor safety awareness, and fall risk, and documented prior falls and the need for specific fall interventions, including non-skid strips in the bathroom, use of a Hoyer lift for all transfers as of 12/7/25, and staff education to use a gait belt when transferring. Nursing progress notes showed a pattern of self-transferring and fall-related events over several months, including documentation that the resident continued to self-transfer, had a witnessed fall during transfer to the toilet, and was being ambulated by staff when she reported her legs were giving out and was lowered to the floor. A Morse Fall Scale assessment scored her at 70, indicating high fall risk. Despite these documented risks and interventions, staff did not consistently follow the care plan and standards of practice. The resident’s care plan called for non-skid strips in the bathroom, but after she changed rooms on 12/3/25, the anti-slip strips were not implemented in the new bathroom. On the date of the major fall event, a CNA assisted the resident into the bathroom without applying a gait belt, despite having been educated on gait belt use and acknowledging she knew one should have been used. The CNA was behind the resident as the resident held onto a support bar; when the resident’s legs gave out, the CNA attempted to hold her by placing her arms under the resident’s armpits but was unable to keep her up and lowered her to the floor. Multiple staff confirmed that at the time of this fall the resident did not have a gait belt on, and that some staff typically used two-person assistance with a gait belt due to the resident’s size. The post-fall evaluation and emergency room X-ray documented fractures of the distal tibia and fibula, and a physician later determined the injury to be a major injury.
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