IDPH has cited and and fined Mason City Area Nursing Home after a resident there fell and suffered a fractured hip while being transferred from her bed to her wheelchair by an aide who was not using a gait belt.
Use of a gait belt is a basic 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. A gait belt is a basic piece of equipment in a nursing home and is provided by the nursing home for staff to use. Its use is often required by the resident care plan and/or facility policies and procedures.
Here, the resident’s Minimum Data Set (MDS) specified that the resident required the assistance of one staff member for transfers, was unable to ambulate, and was unsteady when going from a seated to standing position. The MDS is submitted under penalties of perjury to the federal government and is a statement as to the condition of the resident and the levels of care and assistance that the resident requires. The reason that the MDS is submitted to the federal government under penalties of perjury is that the MDS forms part of the basis by which the nursing home is paid and this is the certification by the nursing home that a) this is the kind of care that the resident requires and b) that the nursing home is in fact providing it.
Here, the facility’s policies and procedures specified that when staff was providing assistance with transfers, a gait belt was required to be in use. Taken together, the MDS and policies and procedures indicated that when this resident was being transferred, there would be physical assistance from one staff member who would be using a gait belt.
On the morning of this nursing home fall, the resident was being transferred from her bed to her wheelchair with the help of a single aide. There was no gait belt in use, as she could not find the one in the resident’s room and someone “stole” hers. As the resident went to turn to get into her wheelchair, her legs crossed over when she attempted to pivot. She lost her balance and began to fall. Had a gait belt been in use then, the aide would have had a chance to either prevent the fall or bring it under control.
However, there was no gait belt in use. As a result, the aide was reduced to trying to bring the fall under control by grabbing at the back of the resident’s pants. This was as ineffective as might be expected and both the resident and the aide fell to the floor. The resident complained of immediate pain to the left hip. She was sent to the hospital where x-rays confirmed a fractured hip. She had to undergo surgery to repair the fractured hip.
Obviously, the most immediate cause of the fall was the failure to use the gait belt. However, when you see staff take shortcuts in the care of a resident such as attempting a transfer without a gait belt rather than taking the time to find this necessary and required piece of equipment, it raises a question of whether the nursing home was understaffed. Sadly, understaffing a nursing home is a feature, not a bug of the nursing home business model. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
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