F0689

G

Failure to Use Gait Belts, Lifts, and Adequate Supervision Resulting in Resident Falls With Fractures

West Des Moines, Iowa Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision, follow its own transfer and ambulation policies, and use appropriate assistive devices to prevent accidents for multiple residents. For one resident with diabetes, stroke, heart failure, severe cognitive impairment (BIMS 3), muscle weakness, and limited ROM, the MDS showed she did not walk 10 feet due to medical/safety concerns and normally used a manual wheelchair. Her care plan identified a brain injury, impulsivity, and non‑compliance with directions, and directed staff to assist her to ambulate with a gait belt and front‑wheeled walker and to transfer using a non‑mechanical lift. She was not on a restorative program, and staff interviews indicated she was mostly in bed, required significant assistance, and had not been ambulating to the bathroom for some time, with CNAs typically changing her in bed and transferring her to a recliner with assistance of two and a gait belt.

On the date of the fall, an incident report and nursing progress notes documented that a CNA reported the resident lost her balance and fell while ambulating to the bathroom, and that the resident was found on the floor on her right side, screaming in pain, without a gait belt, with her walker tipped over nearby and her wheelchair by the bathroom wall. The RN and CNA assisted her back to bed without using a mechanical lift, despite her inability to bear weight, by grabbing her pants and sliding and lifting her into bed. EMS documentation and ED records described that EMS found her after a fall from her wheelchair with severe right shoulder pain, and the ED history stated she fell when trying to use her wheelchair for support while getting out of the shower. Imaging revealed an impacted right humeral fracture and a comminuted olecranon fracture with elbow effusion, and she was admitted for trauma management. The resident’s daughter reported that her mother had been mostly bedbound, could not walk during prior visits, and that she was told by the RN that the CNA had followed the resident with a wheelchair as she walked to the bathroom, which conflicted with her understanding of her mother’s abilities.

Staff interviews revealed inconsistent accounts of the event and failures to follow policy and care plan directions. The RN stated the resident had not gotten up by herself in a long time, that she was found on the floor without a gait belt, and that a mechanical lift was not used to get her off the floor, contrary to facility policy for non‑weight‑bearing or extensive‑assist residents. The CNA involved gave differing versions of the incident, at one point stating the resident was assisted up from the recliner with a gait belt and walker and that a mechanical lift was used to get her into bed, which was contradicted by another CNA who entered the room and observed the resident being placed in bed without a gait belt and without a mechanical lift present. Investigative notes documented that the resident was impulsive, did not always follow directions or wait for staff, and had been caught ambulating on her own, yet the facility’s own documentation also stated she had not been ambulating and required significant assistance, indicating a lack of consistent implementation of care plan interventions and safe transfer policies.

A second resident with weakness, unsteadiness on feet, and intact cognition required one‑person assistance with ambulation and maximal assistance for hygiene and toileting. Her care plan directed staff to assist with ambulation and transfers with moderate assistance of one staff using a gait belt and front‑wheeled walker. On the day of her incident, she walked to the bathroom with her walker, used the toilet, and activated the call light to request staff assistance for peri care. She reported that she waited a long time for help, that when the CNA arrived and began assisting her, she felt herself slipping and told the CNA, who responded "I've got you" but did not prevent her from sliding to the floor. She stated the CNA held her by the arm rather than using a gait belt, and that a second agency CNA came in and both attempted to get her into the wheelchair by her arms while she was unable to stand due to right leg pain, before the nurse arrived.

Facility documentation of this fall described that the resident’s legs became weak during peri care and she was lowered to the floor, and that she was later found in the bathroom in a wheelchair with a gait belt on. The NP’s progress note, however, recorded the resident’s description that she slid down between the toilet and wheelchair when the caregiver did not use a gait belt despite her warnings that she was slipping. X‑rays revealed an acute trimalleolar fracture of the right ankle, and she required hospital evaluation, pain management with Fentanyl, and stabilization with a soft cast. The facility’s fall report and physician form characterized the event as a fall during transfer from toilet to wheelchair with legs becoming weak, but did not reconcile the resident’s account that a gait belt was not used and that she was lifted by her arms by two agency CNAs.

Interviews with the agency CNAs involved in this second resident’s care showed that they were new to the facility, had not been oriented to the electronic record (PCC), did not know resident‑specific information, and were unfamiliar with the facility’s equipment and procedures. One agency CNA described the day as hectic, with staff sick and leaving, and stated that she answered a bathroom call light for a resident she did not know, assisted with peri care, and the resident started to fall. She called another agency CNA for help, and together they struggled to get the resident into the wheelchair before a nurse arrived; she reported that no one asked her what happened and she was not contacted afterward. The second agency CNA similarly described the shift as chaotic, stated she had no idea how to operate the facility’s mechanical lifts, and reported that she found the first CNA with the resident on the floor in front of the toilet, called for a nurse, and helped get the resident up. Nursing and administrative staff interviews acknowledged that agency CNAs were working with minimal orientation, that the ADON and DON were not directly overseeing their onboarding, and that there was uncertainty about how agency staff accessed care plans and fall‑prevention information, contributing to failures to use gait belts and appropriate transfer methods as required by facility policy.

Facility policies on fall occurrences, gait belts, mechanical lifts, and non‑mechanical transfers specified that gait belts should be used when a patient is weak but can bear some weight and is a fall risk, and that mechanical lifts should be used for non‑weight‑bearing or total/extensive assist transfers, while non‑mechanical lifts are appropriate only when a patient can bear partial weight and follow commands. In both residents’ cases, the documented conditions (weakness, impaired balance, need for significant assistance, and in one case inability to bear weight after the fall) and the care plan directions were not consistently followed. Staff failed to use gait belts during transfers and ambulation, did not use mechanical lifts when residents could not safely bear weight, and did not ensure that agency CNAs were adequately oriented to resident needs and facility safety policies, leading to falls with significant injuries for the residents involved.