Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of a gait belt during resident transfers for one of three sampled residents. According to the resident's Minimum Data Set, the individual required partial/moderate assistance for chair/bed-to-chair transfers. During a transfer from wheelchair to bed, the resident reported that the CNA and LVN did not transfer her correctly, resulting in her landing face down on the bed. Multiple interviews with facility staff, including the Social Services Director, Director of Staff Development, and Director of Nursing, confirmed that a gait belt was not used during the transfer, and the transfer was performed inappropriately. A review of the facility's policies indicated that a gait belt must always be used for any resident who is not completely independent, with no exceptions. The staff involved did not adhere to this policy, as confirmed by their own statements and the investigation findings. The incident was documented in the Facility Reported Event and progress notes, and the resident expressed that the staff were rough and did not transfer her correctly, leading to the incident.