The Illinois Department of Health has cited and fined Addolorata Villa in Wheeling when a resident with Parkinson’s Disease and severe dementia fell and fractured his left hip after staff failed to use a gait belt during ambulation, as required by his care plan. The resident was subsequently transferred to a local hospital for treatment of the hip fracture.
The resident in question was originally admitted to Addolorata Villa with multiple medical conditions including Parkinson’s Disease, Dementia, and Obstructive and Reflux Uropathy. A cognitive assessment scored him at 3 out of 15, indicating severe cognitive impairment, meaning he had very limited ability to understand his surroundings or make decisions about his own safety. Because of these conditions, the facility developed a care plan that included specific safety measures whenever staff helped him walk. The plan stated that he was to ambulate, or walk, with “contact guard in the hallway and a gait belt on for safety with a wheeled walker.” A gait belt is a safety device worn around a resident’s waist that gives staff something secure to hold onto in case the person loses their balance.
On the evening of the incident, a registered nurse observed the resident coming out of his bedroom and walking without his walker. The nurse intervened and asked a certified nurse assistant to stay with the resident while she retrieved the walker. The nurse then walked alongside the resident to a common area near the nurse’s station, gave him ice cream, and seated him in a recliner. However, at no point was a gait belt placed on the resident. About thirty minutes later, after finishing his ice cream, the resident stood up and began walking toward the nurse’s station. The nurse provided the walker, but the resident refused it, “waving his hands to signal ‘no.’” The nurse positioned herself on his right side and walked with him toward his room. After approximately five to six steps, the resident leaned to his left, lost his balance, and fell to the floor. The nurse later acknowledged, “The resident was not wearing a gait belt at the time. Having a gait belt in place would have assisted me in supporting him.”
After the fall, the nurse assessed the resident and, with the help of the certified nurse assistant, transferred him to a wheelchair. She administered pain medication, called the family, and obtained orders from the medical director to send the resident to a local hospital. The hospital confirmed that the resident had sustained a left hip fracture. The certified nurse assistant who was present confirmed that the resident “is very confused, hard to re-direct” and that he “did not have any gait belt on” at the time of the fall.
During the state’s investigation, the facility’s Director of Nursing stated that she expected the nurse to use the gait belt since it was one of the interventions in the care plan. The facility’s own gait belt policy, presented by the Administrator, states that “it is the standard of the community to use a gait belt for all residents in accordance with assessed needs, the care plan and standards of practice in order to provide optimal safety.” The policy further specifies that “gait belts are to be used for all transfers that require staff assistance and when assisting residents to ambulate.”
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