Failure to Use Gait Belt During Transfer Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents during a staff-assisted transfer for one resident. Specifically, staff did not use a gait belt while transferring a resident from a wheelchair to a recliner, despite the resident's care plan indicating a need for assistance due to self-care performance deficits related to weakness. During the transfer, the resident's knees gave out, resulting in an assisted fall in which the resident struck her head on a dresser and subsequently sustained a right hip fracture. The incident was documented in the facility's reported incident and medical records, which noted the resident experienced significant pain and was sent to the emergency room for evaluation. The facility's policy on gait belt use, which was in effect at the time, required gait belts to be used during transfers to aid patients and protect them from accidental trauma. The failure to follow this policy and utilize the gait belt during the transfer directly led to the resident's fall and injury.