Failure to Use Gait Belt During Dependent Resident Transfer
Penalty
Summary
Staff failed to provide adequate supervision and assistance devices during a transfer for a resident with Alzheimer's disease and paraplegia, who was fully dependent on staff for transfers. The resident's care plan specified that two staff members were required for assistance and that a gait belt should be used during transfers. However, during an observed transfer, a CNA and an LVN moved the resident from her bed to her wheelchair by grabbing her under the arms and by the back of her pants, without using a gait belt. The resident did not appear to bear weight during the transfer, as her legs were partially contracted. Interviews with the involved staff revealed that both the CNA and LVN acknowledged they should have used a gait belt but failed to do so—one citing forgetfulness and the other a lack of immediate availability. The DON and Administrator confirmed that facility policy required the use of a gait belt for such transfers and that the method used was not safe or in accordance with policy. Review of the facility's policy further confirmed that a gait belt was required for safe transfers involving dependent residents.