Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, unsteadiness on feet, and muscle weakness, who was severely cognitively impaired and required substantial to maximum assistance for transfers, sustained a laceration during a transfer to bed. The incident happened when two CNAs transferred the resident by holding her under the armpits and using the waist of her pants, rather than utilizing a gait belt as required by facility policy. The resident's leg rubbed against the bed frame, resulting in a wound that required hospital treatment and staples. Observations confirmed the wound and that the bed frame did not have any sharp or protruding edges. Interviews with staff revealed that the use of a gait belt was the facility's policy for such transfers, but the CNAs involved had not followed this procedure and one was unaware of the policy. The DON confirmed that a two-person transfer with a gait belt was the appropriate method for this resident. The facility did not have a step-by-step transfer procedure, and the policy on gait belts emphasized their use for safety during transfers. The failure to use the gait belt and follow proper transfer procedures directly led to the resident's injury.