Failure to Address Resident's Unsafe Use of Gait Belt as Wheelchair Restraint
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards for a resident with moderate cognitive impairment, upper and lower extremity range of motion impairment, and total dependence on staff for transfers. The resident, who used a wheelchair and was admitted for rehabilitation services, was observed strapping himself into his wheelchair with a gait belt, a device typically used by aides for transfers. The resident reported using the gait belt to prevent falling out of the wheelchair and stated that staff were aware and approved of this practice. However, there was no care plan addressing the use of the gait belt in this manner, and the resident had only been educated about removing the belt, not about the risks associated with its use as a restraint. Interviews with facility staff, including the DON, DCO, physical therapist, and administrator, revealed that they were aware of the resident's use of the gait belt but did not recognize it as a hazard. The DON and DCO did not perceive a risk since the resident could remove the belt himself, and no policy addressing accident hazards related to this practice was provided. The physical therapist acknowledged the potential for injury if the resident fell while restrained by the gait belt. Despite staff awareness, there was no documented assessment or care planning to address the safety risks associated with the resident's self-use of the gait belt as a restraint in his wheelchair.