Failure to Safely Transfer Residents and Use Required Gait Belts
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer residents in accordance with assessed needs and established procedures, resulting in resident injuries. One resident with severe anxiety, fear of falling, and a documented need for two-person assistance for transfers and standing was transferred by a single CNA who was unfamiliar with the resident’s transfer status. During a wheelchair-to-bed transfer, the CNA attempted to stand the resident, who became frantic and panicked. The CNA, feeling anxious, hurried to complete the transfer instead of stopping to seek additional help or allowing the resident time to calm down. The resident’s leg likely became caught on the wheelchair leg during this process, causing a large skin laceration that required emergent hospital evaluation and repair with nine sutures. Another resident with impaired cognition, right-sided paralysis from a prior stroke, nonverbal status, and a history of falls had a care plan requiring use of a gait belt and one-person assistance for transfers, standing, and ambulation. While assisting this resident from the toilet, a CNA did not use a gait belt as required. After helping the resident to stand, the CNA turned away to remove gloves and wash hands, leaving the resident unsupported. During this time, the resident fell and struck her head on the sink, later complaining of right leg pain and requiring emergent hospital evaluation. The facility’s policy required the use of gait belts for residents who could not independently ambulate or transfer, and restorative staff confirmed that a gait belt was to be used for this resident.
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