Failure to Use Gait Belt During Transfer Results in Resident Fracture
Penalty
Summary
Facility staff failed to safely transfer a resident, resulting in an accident and injury. Staff did not use a gait belt during the transfer, despite the facility's educational guide directing staff to always use a gait belt for safety. The resident, who was assessed as moderately cognitively intact and required substantial to maximal assistance with transfers, was being moved by two staff members who lifted the resident under the arms and by the clothing, rather than using a gait belt. During the transfer, a popping noise was heard, and the resident sustained a closed fracture of the left femur. The facility's policy on safe lifting and movement did not specify when to use a gait belt, and the resident's care plan did not provide direction regarding gait belt use during transfers. Interviews with staff revealed inconsistent understanding and implementation of safe transfer protocols. One CNA stated they were unsure if a gait belt was required and did not recall receiving in-service training on safe transfers, including during orientation. Other staff, including an LPN and the DON, confirmed that staff are directed to use a gait belt or other transfer equipment, and acknowledged the risk of injury when not using proper equipment. The incident report documented that the staff involved were counseled for not following fall protocol, which resulted in the resident's injury.