Failure to Use Gait Belt During Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement required safety and fall prevention interventions during the transfer of a resident with a significant history of falls and multiple behavioral and medical conditions, including dementia, seizures, and muscle disorder. The resident, who was known to be noncompliant with care and at risk for falls, was being assisted to the toilet in the shower room. During the transfer from the toilet back to the wheelchair, the resident insisted on pulling up her own pants, became unstable, and fell, resulting in a head injury. Observations confirmed visible bruising above the resident's left eyebrow following the incident. Interviews and record reviews revealed that the staff member assisting the resident did not use a gait belt during the transfer, despite facility policy requiring gait belt use for residents at risk for falls and those needing assistance during transfers. The staff member attempted to support the resident by placing her arms around the resident's back, but was unable to prevent the fall. The facility's policy and statements from supervisory staff confirmed that gait belts are mandatory for such transfers, and the failure to use this safety device directly contributed to the incident.