Improper Gait Belt Transfer Used Instead of Required Hoyer Lift
Penalty
Summary
Surveyors identified a deficiency in which staff failed to follow the resident’s care plan and transfer requirements, resulting in the use of an inappropriate transfer method. The facility’s policy for gait belt transfers required review of the Kardex for transfer assistance needs and specified proper use of the gait belt. Resident #3’s medical record showed diagnoses of hemiparesis and hemiplegia following a stroke on the right dominant side, severe cognitive impairment, and limited range of motion in one lower extremity. The resident’s care plan and staffing book indicated the resident was dependent for transfers and required a mechanical (Hoyer) lift with assistance of two staff for transfers, with interventions specifically directing use of a Hoyer lift due to fall risk, poor balance, unsteady gait, stroke with right hemiplegia, dementia with impulsivity, and impaired decision making. Despite these documented requirements, observation showed a CNA and an LPN entered the resident’s room to complete a skin assessment and transferred the resident using a gait belt instead of a Hoyer lift. The resident was assisted to stand from the wheelchair with staff on each side, each placing one arm under the resident’s armpit and one hand on the gait belt. The resident’s knees remained bent, the resident stood on toes, staff appeared to strain to hold the resident in a hunched position, and the resident yelled to be put down, stating they were slipping. Staff then repositioned the wheelchair parallel to the bed and again used the gait belt and underarm hold to stand and pivot the resident, during which one foot remained on the ground and twisted while the other foot lifted as staff swung the resident into bed. Interviews confirmed that transfer status is communicated via the Kardex, staffing book, and colored stickers on name plates, and that a pink sticker should have indicated Hoyer transfer status for this resident; however, no pink sticker was present on the name plate at the time of observation. The Administrator and DON stated that if a resident is identified as a Hoyer transfer in the care plan and staffing binder, it is not acceptable to use a gait belt.
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