Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use a gait belt while transferring a resident from her bed to a wheelchair. The resident, who had severe cognitive impairment and required maximal assistance with transfers due to weakness and abnormal gait, was instead lifted by her clothes and under her arms. During the transfer, the resident expressed pain, stating it hurt under her breasts. The resident's care plan specifically required the use of a gait belt and assistance of one staff member for all transfers to prevent injury. Observation confirmed that the CNA did not follow the care plan or facility policy, which mandates the use of a transfer belt for any patient needing assistance with transfers or ambulation. The CNA acknowledged awareness of the requirement and had received training on gait belt use. The facility's policy and the resident's care plan both documented the necessity of a gait belt for safe transfers, but this protocol was not followed during the observed incident.