Failure to Use Assistive Device During Resident Transfer
Penalty
Summary
Staff failed to follow facility policy regarding the use of assistive devices during the transfer of a physically dependent resident diagnosed with Parkinson's disease, muscle weakness, tremors, and difficulty walking. The resident was documented as cognitively intact but had upper and lower extremity impairment on one side and required extensive assistance from two staff members for transfers. The care plan specified that transfers required two staff and that a mechanical lift could be used as needed. However, during observed transfers, two CNAs moved the resident between a recliner and bed without using a gait belt or any assistive device, instead lifting the resident by placing their arms under the resident's armpits and cueing the resident to move his feet. Both CNAs acknowledged during interviews that they should have used a gait belt for the transfer, and this was confirmed by an RN and the DON, who stated that a gait belt was required for this resident during transfers. The facility's policy on safe lifting and movement of residents required staff to incorporate resident safety and to be trained in the use of manual and mechanical lifting devices. The failure to use a gait belt or assistive device during the transfer was directly observed and confirmed by staff interviews, constituting a failure to implement the facility's policy for safe resident transfers.