Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to use an assistive transfer device (gait belt) during a transfer for a resident with a history of myocardial infarction, pneumonia, and congestive heart failure. Observation showed that a registered nurse assisted the resident from bed to wheelchair by holding under the resident's arm and the back of his pants, rather than using a gait belt as required. The gait belt was present in the room but was not utilized during the transfer, and the resident confirmed that staff did not use it for him. Interviews with multiple staff members, including CNAs, the therapy director, and nursing leadership, confirmed that the resident's care plan and transfer profile specified a one-person contact guard assist with a gait belt. Staff consistently reported that gait belts should be used for all transfers unless the resident was independent or required a mechanical lift. Despite this, the nurse did not follow the established protocol, and there was no facility policy in place regarding transfers, with staff expected to follow therapy department recommendations.