Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
Staff failed to follow facility policy and professional standards of practice during a transfer of a resident who was dependent on staff for mobility. The resident, who had multiple medical conditions including acute kidney failure, diabetes, COPD, CHF, anxiety, depression, anemia, and atrial fibrillation, required assistance for transfers and was assessed as moderately cognitively impaired and dependent on staff for transfers. On the evening of the incident, two CNAs assisted the resident in transferring from a wheelchair to bed without using a gait belt, despite being aware of and trained on the facility's policy requiring gait belt use for all assisted transfers. During the transfer, the resident's knees buckled, and the staff had to grab the waistband of the resident's pants to prevent a fall. As a result, the resident's left leg came into contact with an exposed piece of metal on the bed frame, causing a laceration. Both CNAs involved acknowledged in interviews that they did not use a gait belt during the transfer and were aware that this was against facility policy. Documentation confirmed that both CNAs had received training and signed acknowledgments regarding the gait belt policy and proper transfer techniques. The incident was witnessed and reported by nursing staff, and the Director of Nursing and Administrator confirmed that the facility's policy was not followed during the transfer. The failure to use a gait belt directly contributed to the resident's injury during the transfer process.