Failure to Use Gait Belt During Transfer Results in Resident Fall and Major Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate assistance and use required assistive devices during a transfer, resulting in a resident sustaining a fall with major injury. The resident, who had moderate cognitive impairment, a history of repeated falls, and required partial to moderate assistance with transfers, was being assisted by a CNA from bed to wheelchair. During the transfer, the CNA did not use a gait belt as required by the resident's care plan and facility policy, instead holding the resident by her pants and buttocks. The resident slipped and fell, hitting her head on the overbed table and sustaining a laceration and a pelvic fracture. The incident was not witnessed by a nurse, but the CNA involved provided a written statement confirming the lack of gait belt use. The resident's care plan specified the use of a gait belt and limited assistance for transfers, and the facility's policy mandated gait belt use for residents unable to transfer independently. Documentation and interviews confirmed that the plan of care was not followed at the time of the fall. Following the fall, the resident was assessed, treated for a head wound, and sent to the emergency department, where a pelvic fracture was diagnosed. The facility had not conducted monitoring audits of staff compliance with gait belt use after the incident, and the CNA involved was not available for further interview during the survey. The deficiency was directly related to the failure to follow established care plans and safety policies during resident transfers.