Failure to Use Gait Belt and Provide Safe Transfer During Van Transport
Penalty
Summary
A deficiency occurred when a resident with a history of myopathy, leg pain, anxiety, atherosclerotic heart disease, and a history of falls was not properly assisted during a transfer to a transport van for a medical appointment. The resident, who was identified as a fall risk and required one-person assist with transfers, expressed to the CNA that she could not walk to the van and needed a wheelchair. After retrieving a wheelchair, the CNA was unable to place the resident in the designated wheelchair area of the van due to equipment blocking the space and instead attempted to assist her into the front seat without the use of a gait belt. Despite the resident's repeated statements that she lacked the strength to ascend the van stairs, the CNA encouraged her to try and attempted to assist her manually. During the transfer, the resident's legs gave out, resulting in her legs flopping and hitting objects, and the CNA pushed her from behind into the seat. The same process was repeated on the return trip, during which the resident again experienced her legs giving out and was physically lifted and pushed into the seat, resulting in bruising to her knees, legs, and chest. The resident reported pain and bruising, and subsequent imaging showed no fractures. Physical therapy documentation indicated that the resident was a fall risk, experienced dizziness during ambulation, and required contact guard assistance with a gait belt for stair training. Therapy staff confirmed that a gait belt was always used for her safety during such activities. The facility's safe handling program also required the use of gait and transfer belts when manual assistance was needed for ambulation and transfers. The CNA involved admitted to not using a gait belt during the transfer, contrary to facility policy and the resident's care needs.