F0842

D

Incomplete Documentation of Gait Belt Requirement for Resident Transfers

Naugatuck, Connecticut Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a complete and accurate medical record reflecting physical therapy directions for the use of a gait belt during transfers. Resident #1, who had diagnoses including falls and anemia, was cognitively intact with a BIMS score of 15, was dependent for toileting, and required maximal assistance with transfers per the admission MDS. The resident’s care plan identified deficits in functional mobility and potential for falls, with interventions specifying assistance of one staff for transfers. On the date of the fall, an APRN note documented that the resident sustained a fall resulting in a skin tear on the left knee and right forearm while transferring, but the record did not identify that a gait belt was used or required during the transfer.

Interviews and record reviews with the Director of Rehabilitation and the primary Physical Therapist established that, prior to the fall and on the date of the incident, the resident required assistance of one staff and the use of a gait belt for transfers. However, the Physical Therapist had not documented in the therapy notes that a gait belt was required, believing it to be a facility policy, and the Director of Rehabilitation could not provide documentation or evidence of communication to nursing regarding this requirement. The DNS confirmed that at the time of the fall the resident required a one-person stand-pivot transfer, that the resident’s knees buckled leading to the fall, and that there was no physician order, care plan directive, facility policy, or therapy communication specifying the use of a gait belt. This was inconsistent with the facility’s Charting and Documentation Policy, which directed that records provide a complete account of the patient’s stay and information used in developing the plan of care.