F0689

D

Improper Transfer Technique Without Gait Belt Use

Plano, Texas Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe transfer techniques and adequate supervision for a cognitively impaired resident who required assistance with transfers. The resident was an elderly female with dementia, diabetes, and hypertension, severely cognitively impaired with a BIMs score of 3, and care planned to require the assistance of one staff member and extensive assistance for transfers due to generalized and unilateral weakness. Her MDS reflected a history of at least one prior fall without injury, and her care plan interventions included providing an appropriate level of assistance to promote safety during transfers. During interview, the resident reported she had fallen recently and that staff and family had instructed her not to get up by herself, and she acknowledged she was trying to comply by asking for help.

On the observed date, a CNA assisted the resident from her wheelchair to the bed and back without using a gait belt, contrary to the facility’s written transfer policy requiring a gait/transfer belt for bed-to-chair transfers. The CNA instead held the resident’s arm, pulled on the back of the resident’s pants, and later placed both arms around the resident to lift her from the bed to the wheelchair while the resident attempted to hold the bed rail and wheelchair arm for support. The resident was described as very unsteady and shaky, and the CNA struggled to complete the transfer. The CNA acknowledged in interview that staff were not supposed to lift residents under their arms because of potential injury, stated she had been trained on gait belt transfers, and reported she did not see a gait belt in the room. The facility’s policy specified use of a snugly applied gait belt at the waist with stand-and-pivot technique, which was not followed during the observed transfers.