Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, epilepsy, aphasia, and cellulitis of the right lower limb required substantial to maximal assistance for toileting hygiene and transfers, as documented in the care plan and Minimum Data Set. The care plan specifically directed staff to use a gait belt for all transfers. Despite these instructions, a CNA transferred the resident from the toilet to a wheelchair without using a gait belt, instead holding onto the resident's brief during the transfer. During the transfer, the CNA did not notice that the resident's right foot was caught near the wheelchair's leg rest area. As the resident attempted to sit, her right leg, which was contracted due to her medical condition, swung forward and struck the frame of the wheelchair. This resulted in a laceration to the resident's right lower leg, which required emergency medical attention and stitches. The incident was confirmed by interviews with the resident, the CNA involved, and other facility staff, all of whom acknowledged that a gait belt should have been used according to facility policy and the resident's care plan. The facility's policy mandates the use of gait belts for residents who cannot independently ambulate or transfer, and staff receive training on this policy during orientation and annually. The failure to follow this policy and the resident's care plan directly led to the resident sustaining a significant injury during a transfer. The event was documented in the facility's final report and corroborated by medical records from the emergency room.