Failure to Use Required Gait Belt During Ambulation Resulting in Hip Fracture
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards and received adequate supervision during ambulation, resulting in a fall and left hip fracture. The facility’s Fall Management Program policy included staff education and interventions to prevent unsafe transfers and ambulation. The resident had severe cognitive impairment, as evidenced by a BIMS score of 3/15, and used a walker and wheelchair. A Safe Resident Handling Data Collection form documented that a gait belt and walker were required for transfers with staff and that the resident continued to require use of a gait belt. The resident’s care plan included assistance with transfers and ambulation and provision of adaptive equipment, but there was no physician order for a gait belt, and gait belt use was not listed on the care plan. Instead, the Administrator stated that transfer methods, including gait belt use, were communicated via name tags on residents’ doors and that the resident had a history of tripping over her own feet and falling. On the day of the incident, the resident was being assisted by a CNA from the bathroom when the resident’s feet became twisted and she fell to the floor. The CNA reported she was holding the resident’s pants while walking her from the bathroom and acknowledged that the fall was her fault. Documentation indicated the resident fell in her room while being transferred/ambulated from the bathroom with the CNA present, wearing shoes at the time. The Administrator confirmed that the resident had been assessed for gait belt use and that the resident did not have a gait belt on when she fell. The Administrator stated that, in situations where a resident is already in motion without proper equipment, staff should hold the resident and call for help rather than continue ambulation. The resident sustained a subcapital femoral neck fracture of the left hip, required surgical repair at a hospital, and was later readmitted to the facility for rehabilitation and strengthening, with documentation noting she had been confined to a wheelchair prior to the fall and was unlikely to progress beyond her previous level of activity.
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