Failure to Use Gait Belt During Assisted Transfer
Penalty
Summary
A deficiency occurred when staff failed to implement required safety interventions during a transfer for a resident with moderate cognitive impairment and multiple diagnoses, including osteoporosis, osteoarthritis, muscle weakness, and low back pain. The resident's care plan specified that transfers should be performed with maximal assistance of one staff member and the use of a full wheeled walker and gait belt. During an observed transfer, a nursing assistant moved the resident from a wheelchair to a recliner without using a gait belt, instead lifting the resident by wrapping her arms around the resident's torso. The nursing assistant stated that she did not use a gait belt because the transfer was short and did not require steps. Interviews with facility staff, including an LPN and the DON, confirmed that the facility's policy requires the use of a gait belt for all assisted transfers, regardless of the distance. The DON acknowledged that not using a gait belt and lifting the resident by the torso could have caused injury or pain and that there would have been no secure way to assist the resident if she began to fall. Review of the facility's policy further confirmed that staff are directed to apply a gait belt for all wheelchair transfers.