Failure to Use Required Gait Belt During Assisted Ambulation Resulting in Fall With Injury
Penalty
Summary
Staff failed to follow an identified fall-risk resident’s care plan and facility policy requiring use of a gait belt during assisted ambulation, resulting in a fall with injury. The resident, who was cognitively intact with a BIMS score of 15, had diagnoses including CHF, weakness, and hyponatremia, and had been assessed multiple times as being at high risk for falls. His care plan and therapy discharge instructions specified that he required one-person assist with ambulation using a walker and a gait belt, and he was on a walk-to-dine program in which staff were to walk with him to and from meals. The care plan interventions included use of a walker with a gait belt and one assist, wheelchair with foot pedals for distance, and cues to slow down when ambulating. On the day of the incident, the resident was ambulating to the dining room with a certified medication aide who knew he required one-person assist with ambulation but did not apply a gait belt. As they walked, the resident began walking too fast, his walker moved too far in front of him, and despite the aide cueing him to slow down, he tripped over his own feet, fell forward into a table, hit his head, and landed on the floor. He sustained a nasal bone fracture and multiple skin tears on his face and arms and required evaluation in the emergency room. Subsequent observations showed multiple cuts and bruises on his face and arms, and interviews with staff and therapy confirmed that a gait belt should have been used whenever he was assisted with walking, in accordance with his care plan and the facility’s gait belt and falls/accident policies.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.