Failure to Use Gait Belt During Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use a gait belt while assisting a resident with a transfer in the bathroom, despite facility policy requiring its use for all transfers unless contraindicated and documented in the care plan. The resident, who had moderate cognitive impairment and required extensive assistance with transfers, was using a front-wheeled walker and was being assisted by the CNA. During the transfer, the resident tripped and fell backward after washing her hands, resulting in both the resident and the CNA landing on the floor. The CNA admitted to not using a gait belt because one was not immediately visible in the room. The incident led to the resident sustaining a closed nondisplaced fracture of the left radius, requiring emergency room evaluation and immobilization with a sling and splint. Review of the resident's care plan confirmed the need for extensive assistance and use of a walker, and facility policy mandated gait belt use for all transfers. Staff interviews and personnel records indicated the CNA had received training on gait belt use, and the expectation to use a gait belt was reiterated by the Director of Nursing. The failure to follow established policy and training directly contributed to the resident's fall and injury.