Failure to Use Gait Belt During Transfer Results in Resident Distress
Penalty
Summary
A certified nursing assistant (CNA) failed to provide appropriate treatment and care to a resident in accordance with professional standards, the resident's care plan, and the resident's preferences. The CNA did not use a gait belt as required during a transfer from the bed to a wheelchair. Instead, the CNA hooked her arm under the resident's armpit and pulled upward, which caused the resident to express pain multiple times during the transfer attempt. The resident's care plan and facility policy specified that a gait belt must be used for all sit-to-stand transfers and that residents should not be lifted by their arms. The resident involved had a history of dementia, stroke, muscle weakness, and required substantial to maximal assistance with transfers and toileting. The resident was frequently incontinent and used a wheelchair for mobility. The care plan indicated the resident was at risk for falls and injury due to gait and balance problems, poor safety awareness, and cognitive impairment. The resident's assessment and therapy notes confirmed the need for a one-person assist with a gait belt for transfers, and staff had been in-serviced on these requirements. The incident was observed on video footage, which showed the CNA attempting to transfer the resident without a gait belt, resulting in the resident repeatedly stating she was in pain. The CNA eventually sought assistance from a nurse, and the transfer was completed without further incident. Interviews with staff and the resident's roommate corroborated that the resident expressed pain during the transfer. The facility's investigation confirmed that the CNA did not follow the established protocols for safe resident handling and transfers.