Failure to Use Required Gait Belt During Transfer Resulting in Resident Arm Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff used a gait belt during a transfer for a resident who required moderate assistance, resulting in a left arm fracture. The resident had diagnoses including hypertension, hyperlipidemia, diabetes, and a history of fracture, and had a BIMS score of 10/15 indicating mild cognitive impairment. The MDS and Care Plan documented that the resident required moderate assistance with transfers, toileting, and ambulation, and specifically required assist of one (Ax1) with a gait belt (GB) and front-wheeled walker (FWW) for transfers and mobility. A Care Card posted in the resident’s room also indicated Ax1, GB, and FWW for transfers to the bathroom and for mobility. On the date of the incident, a CNA (Staff A) attempted to transfer the resident from the bed to the commode. According to the incident report and Staff A’s written and verbal statements, the resident could not walk as anticipated, and Staff A moved the walker away and “bear hugged” the resident to attempt the transfer instead of using the gait belt as required. During the attempt, the resident’s legs gave out, her arms went up, and Staff A heard a crack in the resident’s left arm as she lowered the resident to the floor. An X-ray later confirmed an acute mildly displaced fracture of the humeral neck/proximal diaphysis with mild medial displacement of the distal fracture fragment. Staff A acknowledged that she did not have the gait belt properly applied and stated that her fault was not grabbing and using the gait belt during the transfer. Interviews with other CNAs and the DON confirmed that facility policy and practice required the use of a gait belt for any resident needing assistance with transfers and ambulation, and that the Care Card in the room is the reference for transfer status. Staff C and Staff D stated that a gait belt is always to be used for assist-of-one transfers and that this expectation is reviewed during orientation and reinforced in practice. The DON stated that Staff A was aware of the gait belt policy and the Care Card instructions, and that there had been no documented change in the resident’s transfer status from assist of one. The DON also reported prior awareness that Staff A had transferred residents without a gait belt on previous occasions, and that staff are instructed they may increase, but not decrease, the level of assistance from what is documented on the Care Plan and Care Card.
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