Resident Fall Due to Failure to Use Gait Belt During Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident without using a gait belt, contrary to the facility's Safe Resident Handling/Transfers Policy. The resident, who had a history of hemiplegia and hemiparesis following a stroke and was on anticoagulant medication, required substantial to maximal assistance with transfers and was care planned to use a walker and one-person assistance. During a transfer from wheelchair to bed, the CNA did not use a gait belt, resulting in the resident falling forward and sustaining a head laceration that required staples. The facility's policies required the use of handling aids such as gait belts during transfers and mandated that staff follow safe handling practices as outlined in each resident's care plan. The resident's care plan and therapy communication sheets prior to the incident did not explicitly state that a gait belt was required for transfers, although staff interviews confirmed that using a gait belt was considered standard practice for pivot transfers. The CNA involved acknowledged forgetting to use the gait belt during the transfer, despite knowing it was required. Interviews with facility staff, including the DON and therapy staff, confirmed that the omission of the gait belt during the transfer was the root cause of the fall. The care plan was not updated to specify gait belt use until after the incident. The resident's medical record and interviews confirmed the injury and subsequent treatment, and staff interviews revealed inconsistencies in the timing and documentation of staff education regarding gait belt use.