F0689

D

Failure to Use Gait Belt During Transfers Resulting in Multiple Falls

Walkersville, Maryland Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the use of a gait belt during transfers for a resident with significant right-sided hemiplegia/hemiparesis following a stroke, resulting in three avoidable falls, one with injury. The resident was admitted in mid-October 2025 after an acute hospitalization with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, generalized muscle weakness, difficulty in walking, aphasia, anxiety, and pain following cerebral infarction. The resident was documented as cognitively intact and required substantial/maximal assistance for bed mobility, sit-to-stand, transfers, and walking 10 feet. The admission assessment also documented a prior fall within the month before admission.

On admission, an ADL care plan initiated on 10/15/25 documented that the resident required moderate assistance of one person with transfers and the use of a gait belt. Despite this, on 10/24/25 the resident experienced a witnessed fall in the bathroom while transferring from a wheelchair to the toilet with a GNA. The nurse’s note documented the fall and that the resident was assisted from the floor, completed toileting, and was placed in bed for examination, but no Fall Assessment was completed following this event. The following day, a care plan note documented the witnessed bathroom fall and added an intervention specifying that a gait belt was to be used with all transfers, indicating that the resident had already had an actual fall.

On 11/6/25, the resident had another witnessed fall during a transfer from bed to wheelchair with a GNA. The nurse documented that the resident’s knees buckled, the resident went to the floor, and sustained abrasions on both knees. The nurse further documented that, per the GNA, a gait belt was not used during this transfer. A telemedicine visit by an APN documented a fall with injury, including abrasions to both knees and the left elbow, and treatment was ordered. A subsequent nursing review documented small bilateral skin tears to the knees. In a later interview, the GNA assigned to the resident on that date stated they were not aware at the time that a gait belt was supposed to be used for this resident and did not think the resident had been issued a gait belt, despite having received gait belt training at the facility.

On 11/27/25, the resident experienced a third witnessed fall while transferring from the toilet to a chair, during which the GNA lowered the resident to the floor. Documentation indicated there was no injury. A Change in Condition review and Fall Assessment documented a witnessed fall with no injury, baseline pain, and normal range of motion, but there was no documentation that a gait belt had been used during this transfer. Further review found no documentation that the physician or the resident’s representative had been notified of this fall, and no vital signs were obtained at the time of the fall; the review instead listed vital signs from 12/11/25. The review was signed on 12/11/25, despite an effective date of 11/27/25, and there was no evidence of a thorough assessment at the time of the fall.

Therapy staff interviews confirmed that a gait belt had been implemented for the resident from admission and that the resident’s family had provided a gait belt. The COTA and PT stated that residents requiring minimal, moderate, maximum, or contact guard assistance with transfers should use a gait belt, and that this resident had his/her own gait belt and signage placed on the wheelchair, overbed tray, and door after the first fall instructing staff to use a gait belt. The PT stated that after evaluation, a communication form with functional status is placed in the paper chart, and that all GNAs should know that residents needing one- or two-person assistance for transfers require a gait belt. The resident reported having had a gait belt since admission, that staff knew they were supposed to use it but sometimes did not, and that the resident still had to remind staff to use the gait belt during transfers. The DON acknowledged that staff were expected to know which residents required gait belts based on documentation and training, and was made aware that staff had transferred this resident without a gait belt on multiple occasions, resulting in three avoidable falls, including one with injury, and that fall assessment documentation was incomplete.