Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents during a transfer. Specifically, two staff members, an RN and a CNA, transferred a resident from the floor to her wheelchair without using a gait belt and instead lifted her by placing their arms under her armpits. This method of transfer was observed in a video provided by a family member and was reviewed by facility leadership, who confirmed that it was not in accordance with facility policy or standard practice. The resident involved was an elderly female with multiple diagnoses, including coronary artery disease, hypertension, renal insufficiency, hyperlipidemia, and dementia, resulting in severe cognitive impairment. Her care plan indicated she required partial to moderate assistance for transfers and was able to bear weight and pivot with support. Staff interviews and record reviews confirmed that the resident was assessed as a one-person transfer with a gait belt for all transfers, and that staff had been trained and were expected to use gait belts rather than lifting under the arms. Multiple staff members, including the DON, CNA, LVN, and PT, acknowledged that transferring a resident by lifting under the armpits was not appropriate and could cause injury. The facility's policy and in-service training materials also specified the use of gait belts and prohibited lifting residents by or under their arms. Despite this, the observed transfer did not follow these protocols, resulting in a deficiency related to accident prevention and safe transfer practices.