Improper Transfer Without Gait Belt During Resident Shower Transfer
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to properly transfer a resident who was dependent for transfers and at risk for falls, as documented in her care plan and MDS assessment. The resident, who had diagnoses including cerebral infarction, type 2 diabetes mellitus, obstructive sleep apnea, and functional quadriplegia, required total assistance for transfers and hygiene. On the day of the incident, the CNAs attempted to transfer the resident from her bed to a shower chair without using a gait belt, contrary to facility policy and standard safe transfer practices. During the transfer, the resident's legs gave out, and she was lowered to the floor by the CNAs, who held her under the arms rather than using proper technique. Interviews with the involved staff confirmed that a gait belt was not used during the transfer, and the CNAs acknowledged this was not in accordance with training or facility policy. The Director of Rehabilitation also confirmed that a gait belt should be used for all transfers and that lifting under the arms is improper and potentially harmful. The facility's Safe Lifting and Movement of Residents policy requires the use of gait belts and mechanical lifting devices as appropriate, and staff are to be trained in their use. The failure to follow these procedures resulted in the resident being lowered to the floor during the transfer, though no injuries were noted at the time.