IDPH has cited and fined Pleasant View Lutheran when a resident, who should have been wearing a gait belt, suffered a fall that resulted in a fractured femur. The fracture ultimately contributed to the resident’s decline and death a short period after the fall.
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 to 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 residents at risk for injury.
The resident in question was diagnosed with Alzheimer’s Disease, General Anxiety Disorder, Chronic Kidney Disease and Muscle Weakness (generalized).
The facility’s Gail Belt / Transfers Policy required that resident’s requiring assistance for ambulation, such as the resident in question, were also required to use a gait belt during assisted ambulation.
On the day of the incident the resident fell while being assisted by a Certified Nursing Assistant (CNA). The incident report states, “Resident was ambulating with CNA and wheeled walker when she tripped over her feet.”
Hospital records confirmed a left hip fracture.
Interviews with staff revealed concerning details about the incident. A Registered Nurse (RN) reported hearing about the fall and assessing the resident afterward. The RN stated, “I saw that the resident did not have a gait belt on. The resident was a one assist with stand-by so the CNA probably should have had one (gait belt) on her.” The RN also mentioned that the resident claimed the CNA was on her phone during the incident.
The CNA involved admitted to not using a gait belt, saying, “I did not have a gait belt on her at that time. I should have, but for the most part she was independent, and she was coming out the door and I didn’t grab it quick enough, and we just kept going.” When asked what could have been done differently, the CNA acknowledged, “Obviously used a gait belt.”
Following the fall and subsequent surgery, the resident’s condition deteriorated rapidly. Progress notes indicate increased confusion and lethargy. The resident was admitted to Hospice and passed away shortly thereafter. The death certificate listed “Aspiration Pneumonia due to Congestive Hypertensive Cardiovascular Disease” as the primary cause of death, with “Fracture of the Femur due to a fall” listed as a significant contributing condition.
The resident’s physician confirmed the impact of the fall on the resident’s decline, stating, “No question about it that (the resident’s) fall with fracture exacerbated her decline and subsequent death. She was so frail.” The Physician also noted the high mortality risk associated with long bone fractures in elderly patients.
This case highlights a significant failure in resident safety protocols, particularly in the proper use of gait belts during assisted ambulation, which directly contributed to a resident’s injury and subsequent death.
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. 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.
