Failure to Use Gait Belt During Transfer for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and use of required safety equipment during transfers for a resident at high risk for falls. The resident had moderately impaired cognition with a BIMS score of 12, diagnoses including cerebrovascular accident, multiple sclerosis, disorientation, and a history of repeated falls. The MDS and care plan documented that the resident required partial to moderate assistance and assistance of one staff member for all transfers, and a Fall Risk Assessment score of 16 identified the resident as high risk for falls. On the date of the incident, an Incident Report documented that the resident fell in her room during a transfer, with no apparent injuries, and that a gait assistive device was not used at the time of the fall. According to staff interviews, the CNA responding to the resident’s call light found the resident slouched in a recliner, appearing different than usual, with very wet pants. The CNA attempted to assist the resident to stand and noted the resident felt uneasy and needed to sit back down. On a subsequent attempt, the CNA stood the resident and began turning her toward a motorized scooter while only lightly touching and guiding the resident’s hips, without applying a gait belt. The resident’s legs gave out and the CNA lowered her to the floor, using her arms under the resident’s arms and ensuring the resident’s legs did not twist and her head did not hit the bed’s footboard. The CNA later acknowledged that the resident was supposed to have a gait belt during transfers but stated she did not know this at the time and had observed other staff transferring the resident without a gait belt. The Administrator confirmed there was no formal gait belt policy, only a gait belt acknowledgement form signed during orientation, while staff leadership stated it was an expectation that any resident requiring assistance with transfers use a gait belt.
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