Failure to Use Gait Belt During Assisted Toilet Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly and safely transferred with the use of a gait belt, as required to prevent or minimize the risk of falls. The resident had a history that included right quadriceps strain, orthopedic aftercare, difficulty walking, osteoarthritis, and a prior fall, and was assessed as being at risk for falls. The resident’s MDS documented dependence for toilet transfers, meaning the helper does all the effort or two or more helpers are required, and the care plan identified fall risk and ADL self-care deficits related to limited mobility, weakness, and prior tendon tear and repair. The care plan interventions included assistance with toileting and, after a fall, specified use of a gait belt during transfers, but prior to the fall there was no documentation that a gait belt was not required. Therapy documentation showed that physical therapy recorded supervision or touching assistance with toilet transfers and occupational therapy documented toileting with “CGA,” later clarified by a therapist as contact guard assistance, indicating the resident still required some contact assistance. There was no documentation in the medical record or therapy notes stating that a gait belt was not required for this resident’s transfers. The facility’s Safe Resident Handling/Transfers policy stated that all residents require safe handling when transferred, that handling aides may include gait belts, and that lifting and transferring are to be performed according to the resident’s individual plan of care. On the night of the fall, staff heard a noise consistent with a fall and found the resident on the bathroom floor in an upright position with both legs extended, without a gait belt in place. The resident reported that an aide had assisted him to stand and pivot to the toilet and later to stand after toileting, and he did not recall a gait belt being applied before standing; he also reported becoming lightheaded and falling. The CNA who assisted the resident stated she did not put a gait belt on the resident, described him as a one-assist transfer, and acknowledged staff were supposed to use a gait belt with transfers unless the resident was independent, and that she had never been told this resident did not require a gait belt. Another CNA reported that if a gait belt was not available, he would still transfer a resident without one and just be extra careful. Other staff, including a CNA and a PT, stated that a gait belt should always be used with transfers unless a mechanical lift is used, and the DON stated that gait belt use depends on therapy recommendations, though no documentation existed that a gait belt was not required for this resident.
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