Failure to Use Gait Belt During Transfer for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide a safe transfer for a resident with a progressive neurological condition, Parkinson's disease, muscle weakness, gait abnormalities, and severe cognitive impairment. The resident was identified as high risk for falls and required partial to moderate assistance with transfers, as documented in the Minimum Data Set and care plan. Despite these documented needs and facility policy, a Certified Nurse Assistant (CNA) assisted the resident in transferring from a recliner to a wheelchair without using a gait belt. The CNA acknowledged not using the gait belt and stated that its use depended on the resident's anxiety level, even though the expectation was to always use it for this resident. Multiple staff, including a Registered Nurse, Physical Therapist, and the Director of Nursing, confirmed that all staff are expected to use a gait belt when transferring or walking with this resident. During observation, the gait belt was found unused and rolled up on the counter in the resident's room. The facility's Falls Prevention and Post-Falls Management Policy requires staff to identify fall risks and implement resident-centered prevention plans, which includes the use of assistive devices like gait belts. The failure to use the gait belt as required led to a deficiency in providing adequate supervision and accident hazard prevention.