Failure to Use Gait Belt During Transfer Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use a gait belt while transferring a resident from the toilet to a wheelchair. The resident, who had a history of stroke with right-sided hemiplegia, generalized muscle weakness, and was on anticoagulant therapy, required substantial to maximal assistance with transfers as documented in her care plan and MDS assessment. The care plan specifically instructed staff to use a gait belt for all transfers due to the resident's fall risk and right-sided weakness. On the day of the incident, the CNA assisted the resident off the toilet without applying a gait belt, despite the resident's request for help and her care plan requirements. During the transfer, the resident lost balance and fell, resulting in significant injuries including a 10th rib fracture, a right tibia spiral fracture, and proximal and distal right fibula fractures. The resident reported severe pain and was subsequently transported to the hospital for evaluation and treatment. Interviews with the resident, her responsible party, and multiple staff members confirmed that the gait belt was not used during the transfer, and that the resident did not refuse its use. Staff interviews also indicated that the use of gait belts for transfers was standard practice and that gait belts were readily available in resident rooms. Further review of facility records, including the resident's care plan, fall risk assessment, and staff training materials, confirmed that the expectation was for gait belts to be used for all transfers requiring staff assistance. The CNA involved acknowledged forgetting to use the gait belt and recognized the risk of falls associated with not following this protocol. Other staff consistently reported that gait belts were mandatory for transfers and that failure to use them could result in resident injury.