Failure to Use Gait Belt During Assisted Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident who required assistance with transfers and ambulation, including the use of a gait belt, was not provided with this safety device during a transfer. The resident had a history of heart failure, acute respiratory failure, muscle weakness, and previous falls, and her care plan indicated she needed partial to moderate assistance with transfers and ambulation, as well as the use of a walker. On the date of the incident, the resident was being assisted to the bathroom with her walker by a nursing assistant, but a gait belt was not used. During this transfer, the resident fell and subsequently experienced increased pain in her left arm and shoulder, which was later diagnosed as a nondisplaced fracture of the neck of the acromion. Interviews and document reviews revealed that while staff generally reported using gait belts for transfers and ambulation, the resident stated that a gait belt was not used at the time of her fall and that staff used the gait belt about 90% of the time. The nursing assistant involved in the incident confirmed that she had not used a gait belt during the transfer and had not been specifically instructed to do so for one-person assists, despite facility policy requiring gait belt use for all such transfers. The care plans did not explicitly direct the use of gait belts, relying instead on facility policy and standard practice.