F0689

G

Failure to Provide Required Contact Guard Assist and Gait Belt Use Resulting in Resident Fall With Injuries

Novi, Michigan Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement required fall-prevention interventions and adequate supervision for a high fall-risk resident, resulting in a fall with injuries. The resident was admitted with a history of a fall with femur fracture and other diagnoses including diabetes, COPD, UTI, urinary retention, and adjustment disorder. A fall risk assessment completed in December scored the resident as an 18, which the facility defined as high fall risk. The resident’s walker had a red tag indicating the need for contact guard assist (CGA) and use of a gait belt when ambulating, and the facility’s policy required residents who could not independently ambulate or transfer to use a gait belt for safety.

On the night of the incident, a nurse documented that around 1:15 a.m. a loud sound was heard from the resident’s room, and the nurse found the resident sitting on the floor with the walker between their legs, bleeding from the forehead with a right arm skin tear and bilateral leg skin tears. The resident was sent to the hospital and later returned with sutures to the forehead, bruising to the left temporal area, and dressings and steri-strips to multiple skin tears. A physician note referenced a mechanical fall with scalp laceration requiring sutures. The resident and family later reported via a complaint form that the resident, who used a walker and was recovering from surgical repair of a broken femur, had been assisted to the bathroom by an aide and fell while walking back toward the bed because the aide did not physically support the resident.

During the facility’s investigation, the resident initially alleged that the CNA pushed them, but provided inconsistent statements. Another CNA reported that the resident and the resident’s daughter stated the aide involved was not close enough to prevent the fall. In a telephone interview, the CNA who assisted the resident acknowledged answering the call light, assisting the resident to the bathroom, and then allowing the resident to ambulate back to the bed with a walker. The CNA stated the resident lost balance while backing toward the bed, became tangled in the walker, and fell, and admitted they were not close enough to get a hand on the resident to prevent the fall. The CNA further acknowledged knowing the red tag on the walker meant the resident required CGA and a gait belt, but they did not provide contact guard assist or use a gait belt at the time of the fall. The Rehabilitation Director and DON both confirmed that CGA required staff to be right next to the resident with a hand on or near them and that a gait belt should have been used for this resident.