IDPH has cited and and fined Fair Oaks Rehabilitation & Health Care Center in South Beloit after a resident there fell and suffered a broken hip due to the failure of a therapist to use a gait belt while walking with the resident.
Use of a gait belt is a fundamental fall prevention strategy. A gait belt is a sturdy canvas strap that is applied to the midsection of a resident who is at risk for falls and may require the physical assistance of staff with walking, standing, and transfers. The gait belt allows the staff member assisting the resident help steady the resident in the event that there is a loss of balance or to break a fall or control the descent if there is in fact a fall. Without the use of a gait belt, the staff would have to rely on grabbing onto the clothing or to the resident to try to prevent a fall. Either places both staff and resident at risk for injury.
The resident at issue was considered at risk for falls and had been assessed as not being steady during transitions and walking and required the extensive assist of one staff member with walking in the corridor. Extensive assist has a particular technical meaning – it means that the staff member is providing some physical assistance with the weight bearing. Doing this properly requires the use of a gait belt.
On the day of this nursing home fall, the resident was being walked back from therapy by a COTA (certified occupational therapy aide). There was no gait belt in use. The aide later told the state surveyor, “[The resident] should have had a gait belt on for a security belt because she was unsteady. I should have had a gait belt on her. I don’t know why I didn’t use one.” As they walked down the hall, a nurse sitting at the nurse’s station observed the resident and the aide, later telling the surveyor that it looked like the aide was not paying attention. The resident began to tire and reached back to sit in a wheelchair, but instead fell to the ground, suffering a fractured left hip which required surgical repair.
Here, there was a failure in the fundamentals which led to this fall. And it was not for a lack of equipment – the rehab director told the state surveyor that there was a drawer full of gait belts available in the therapy department. Simple failures lead to very preventable accidents.
It is worth noting that the primary culprit in this incident was the therapy aide. Frequently in nursing homes, therapy services are provided by an outside contractor. However, the therapy aide was not the sole person bearing some responsibility for this fall as the nurse saw the aide walking with the resident and failed to act to correct the dangerous situation of walking the resident with no gait belt.
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