Failure to Use Gait Belt During Resident Transfers
Penalty
Summary
Staff failed to ensure the safety of a resident with a history of repeated falls, weakness, and impaired mobility by not using a gait belt during multiple observed transfers between a recliner and a wheelchair. On several occasions, various staff members, including CNAs, a CMA, an RN, and the administrator, assisted the resident in transferring without the use of a gait belt, despite the resident's care plan indicating a high risk for falls and the need for partial to moderate assistance with transfers. The resident was observed being transferred by staff members who used their hands to lift him by the arms, rather than utilizing a gait belt as a safety measure. Interviews with staff revealed inconsistent knowledge and application of gait belt use, with some staff acknowledging that a gait belt should be used for this resident and others uncertain about the care plan requirements. The administrator confirmed that gait belt usage had been an ongoing issue and that staff had been instructed to use them during transfers. Review of the facility's Gait Belt Safety policy indicated that therapy staff were required to use gait belts for all transfers, but the policy did not address requirements for non-therapy staff, contributing to the lack of consistent implementation.