Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA), identified as agency staff, failed to use a gait belt while transferring a resident who required maximum assistance with transfers. The resident, a cognitively intact female with diagnoses including generalized muscle weakness and urge incontinence, was care planned to require one-person assistance and the use of a gait belt for transfers and toileting. Despite this, the CNA assisted the resident from the commode to a wheelchair without a gait belt, instead pulling the resident up by her pants, which caused distress to the resident and concern from her family members. Family members reported that the CNA was rough during the transfer and did not use the gait belt that was available in the room. The resident was visibly upset after the incident, and family members relayed their concerns to facility staff. The facility scheduler and the Director of Nursing (DON) were both informed of the incident, with the DON confirming that a gait belt should have been used for safety during transfers. The CNA admitted to not using a gait belt and described assisting the resident by pulling her up by her pants due to the resident's foot getting stuck and her knee locking during the transfer. Further review revealed that the facility did not have a policy in place for one-person or gait belt transfers. The DON acknowledged that agency staff were not provided with additional training and that the facility relied on removing agency staff who did not meet expectations. The lack of a clear policy and failure to ensure the use of appropriate transfer techniques led to the deficiency in providing adequate supervision and assistance devices to prevent accidents.