Failure to Use Required Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and the required assistive device during a transfer, as observed during a staff interaction. Specifically, two CNAs transferred a male resident with moderate cognitive impairment, multiple medical diagnoses including Parkinson's disease, diabetes, and blindness, from a wheelchair to a bed without using a gait belt, despite this being a documented requirement in the resident's care plan and facility policy. Both CNAs lifted the resident by placing their arms under his arms and pulling him to a standing position before pivoting him to the bed. Interviews with the involved CNAs revealed that they were aware of the requirement to use a gait belt for transfers and had previously received in-service training on this procedure. Both staff members acknowledged that not using a gait belt posed risks to the resident, including falls and injuries, and admitted there was no reason for not following the protocol during the observed transfer. Additional interviews with an LVN and the DON confirmed that the expectation was for all transfers to be performed with a gait belt unless contraindicated, and that the resident in question had no restrictions for gait belt use. A review of the facility's transfer policy further supported that residents requiring assistance should be transferred using a gait or transfer belt, and that staff are trained to use proper procedures and assistive devices. The policy outlines specific steps for two-person assisted transfers, including the application of a gait belt, which was not followed in this instance. This lapse in protocol was directly observed and confirmed through staff interviews and record review.