Failure to Use Gait Belt During Transfer Results in Resident Fall and Injury
Penalty
Summary
A staff member failed to follow facility policy and procedure regarding the use of a gait belt during a resident transfer, resulting in a fall. The incident involved a resident who was identified as a high fall risk, with diagnoses including muscle weakness, chronic respiratory failure, and chronic kidney disease with heart failure. The resident required substantial to maximal assistance for transfers and was cognitively intact. During the transfer from bed to wheelchair, the CNA did not use a gait belt as required by facility policy and instead held the resident by her pants, leading to the resident falling backward and sustaining injuries. The resident's family member witnessed the aftermath of the fall, finding the resident on the floor with blood coming from her head. The clinical record and hospital documentation confirmed that the resident suffered an abrasion to the forehead and a nondisplaced intertrochanteric fracture of the right femur, which required emergency surgery. The CNA involved acknowledged not using a gait belt and reported that care sheets were unavailable at the time of the incident. Multiple staff interviews confirmed that the use of gait belts was standard practice for all transfers unless a mechanical lift was used. Facility documentation showed that the CNA had completed training on gait belt use and that the facility's policies clearly required gait belts for all non-independent transfers. The failure to use a gait belt during the transfer directly led to the resident's fall and subsequent injury.