Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
Staff failed to follow the established plan of care and facility policy requiring the use of a gait belt during transfers for a resident with dementia, difficulty walking, and osteoporosis. The resident's care plan specifically indicated the use of a gait belt when additional assistance was needed due to weakness. On the night of the incident, staff attempted to assist the resident, who was found attempting to transfer themselves, and subsequently became too weak to bear weight. Staff members transferred the resident from the floor to a wheelchair and then to bed without using a gait belt, despite facility policy and care plan directives. During the transfer, the resident experienced pain and later was found to have sustained a left clavicle fracture, as confirmed by hospital records. Staff interviews revealed that the gait belt was not used because they felt the situation required immediate action, and they did not retrieve the device. The Director of Nursing and Administrator both stated that staff were expected to follow the care plan and use the gait belt as required. The failure to use the gait belt during the transfer directly resulted in harm to the resident.