Failure to Use Gait Belt During Resident Transfer Resulting in Fracture
Penalty
Summary
A 91-year-old female resident with multiple diagnoses, including muscle weakness, lack of coordination, restless leg syndrome, acute respiratory failure, and mild cognitive impairment, required two-person physical assistance with transfers using a gait belt, as documented in her care plan and Kardex. On the date of the incident, a CNA and an RN attempted to transfer the resident from her bed to a wheelchair without using a gait belt, contrary to her care plan instructions. During the transfer, the staff found the resident too heavy to move safely and lowered her to the floor, resulting in the resident sitting on the floor with bent knees. Following the transfer, the resident complained of knee pain and was subsequently given pain medication. An x-ray was ordered and revealed a displaced periprosthetic distal femoral fracture. The resident was transferred to the hospital, where she underwent surgery to insert an intramedullary rod in her right femur. The incident was confirmed through staff interviews, which revealed that the staff did not use a gait belt during the transfer, despite being aware that it was required for the resident's safety. Staff interviews further indicated that the failure to use a gait belt was due to a lack of adherence to the resident's care plan and transfer protocols. Both the CNA and RN involved in the transfer acknowledged not using the gait belt and described their attempts to lift the resident under her arms and by holding her brief, which was not in accordance with safe transfer practices. The facility's policy required the use of appropriate techniques and devices, such as gait belts, to ensure resident safety during transfers, but this was not followed in this instance.