Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to implement standards of practice to ensure a safe transfer for a resident with severe cognitive impairment and multiple physical limitations. The resident, who had diagnoses including Alzheimer's disease, morbid obesity, multiple fractures, and severe cognitive impairment, required substantial to maximal assistance with all transfers and was identified as high risk for falls. Despite care plan and facility policy expectations for the use of a gait belt during transfers, staff assisted the resident in a transfer without applying a gait belt, instead using the resident's clothing for support. During the transfer, the resident tripped and was lowered to the floor by the nursing assistant, resulting in actual harm. The resident sustained a fractured and dislocated left arm, multiple rib fractures, and required emergency department evaluation, medical treatment, and overnight observation for pain control. Documentation and interviews confirmed that the gait belt was not used during the transfer, and staff had a pattern of not consistently using gait belts, sometimes relying on residents' clothing for support. The resident's cognitive status was such that she could not make informed decisions regarding refusal of safety devices, and staff were expected to use a gait belt regardless of any prior refusals. Observations and interviews revealed that staff were not consistently trained or audited on the correct use of gait belts, and there was confusion regarding proper transfer techniques, including where staff should position themselves during transfers. The facility's own policies required assessment and use of appropriate safety devices, including gait belts, for residents at risk of falls. The failure to use a gait belt as required directly led to the resident's fall and subsequent injuries.