Failure to Use Gait Belt During Resident Transfer Results in Fall
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions, specifically the use of a gait belt, for a resident with severe cognitive impairment and multiple diagnoses including Alzheimer's disease, non-Alzheimer's dementia, and restless leg syndrome. The resident was assessed as dependent on staff for toilet transfers and required partial to moderate assistance for walking. According to the care plan, the resident was at risk for falls and required assistance from one to two staff members for walking and transfers. Despite these documented needs and facility policy requiring the use of gait belts for safe lifting and movement, a staff member assisted the resident without a gait belt during a transfer to the bathroom. During the incident, the staff member, who was a traveling nurse, asked other staff about the resident's assistance needs and was told the resident was an assist of one. While attempting to help the resident use a commode, the staff member used one hand to adjust the commode and the other to support the resident, who then stepped backward and fell. The resident later reported pain following the fall. Interviews confirmed that the gait belt was not used during this transfer, although it was typically used for this resident. The DON confirmed that staff should use a gait belt for residents requiring assistance of one or two for transfers.