Failure to Follow Two-Person Transfer and Gait Belt Protocol for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with a history of multiple falls and severe cognitive impairment from a wheelchair to the toilet without the required use of a gait belt and without a second staff member present, as specified in the resident's care plan and the facility's policies. The CNA used the resident's waistband and incontinence brief to lift her, which resulted in the brief tearing and the resident being unable to bear full weight during the transfer. The resident, identified as a high fall risk by a yellow wristband, was wearing only socks at the time, and the CNA was unaware that shoes were available for her. The CNA left the resident unattended in the bathroom to seek assistance, and only upon return with another CNA was a gait belt used and the transfer completed according to protocol. The resident's electronic medical record (EMR) and care plan clearly indicated the need for a two-person assist and the use of a gait belt for all transfers, due to her multiple diagnoses including dementia, Alzheimer's disease, and a recent history of falls. The facility's policies also required staff to verify transfer techniques and use gait belts unless contraindicated or refused. Despite these documented requirements, the CNA failed to follow established procedures, resulting in an unsafe transfer process for the resident.