Failure to Use Gait Belt During Assisted Transfer Results in Resident Fall and Hip Fracture
Penalty
Summary
A deficiency occurred when staff failed to use safe transfer techniques, specifically by not utilizing a gait belt during an assisted transfer for a resident with a history of stroke, hemiplegia, repeated falls, and moderate cognitive impairment. The resident's care plan and fall risk assessment both specified the need for assistance from one staff member with a walker and gait belt for transfers and ambulation. On the day of the incident, the resident was being assisted from bed to the bathroom by a CNA, who did not use a gait belt as required, despite knowing the resident's transfer status and the facility's policy. During the transfer, the CNA turned her head momentarily, at which point the resident lost balance while attempting to turn and sit on the toilet, resulting in a fall into the shower. The resident struck her head on the shower bar, and the walker landed on her, causing swelling to the upper eyelid and significant pain in the right hip. The resident was subsequently assessed and found to have a right hip fracture, requiring transfer to the emergency room and further surgical intervention. Interviews with multiple staff members confirmed that the use of gait belts for hands-on assistance during transfers and ambulation was standard practice, with gait belts readily available and considered part of the uniform. The facility's policy required all direct care staff to use gait belts whenever hands-on assistance was needed, and the resident's care plan clearly indicated this requirement. Despite this, the CNA did not retrieve or use a gait belt during the transfer, directly leading to the resident's fall and injury.