Failure to Use Gait Belts During Transfers Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with a resident’s comprehensive person-centered plan of care and facility policy regarding gait belt use during transfers. The facility had a written policy, dated April 2025, requiring that gait belts be used when physically transferring or ambulating residents. The resident involved had vascular dementia, hypertension, hypothyroidism, a history of repeated falls, difficulty walking, and documented short- and long-term memory problems. The resident’s MDS and CNA care card indicated dependence on staff for activities of daily living, including transfers, and the care plan for impaired functional mobility required staff assistance for transfers and ambulation. On the morning in question, nursing staff requested that the Assistant Director of Nurses assess a bruise on the resident’s right knee. The Assistant Director of Nurses found the knee bruised and swollen, notified the Nurse Practitioner, and obtained an order for an x-ray. A nurse progress note and a mobile x-ray report dated the following day documented an acute distal right femoral metaphysis fracture. The Assistant Director of Nurses conducted an investigation and determined that the injury most likely occurred during a transfer from chair to bed. During interviews, multiple CNAs reported transferring the resident without using a gait belt, contrary to facility policy and the resident’s care needs. One CNA stated he had previously transferred the resident by lifting from the bed with another CNA without a gait belt. Another CNA reported assisting with stand-pivot transfers of the resident on previous days without a gait belt. A third CNA stated that she and another CNA had transferred the resident from wheelchair to bed by lifting and pivoting the resident without using a gait belt on the afternoon prior to the bruise being noticed, and acknowledged that a gait belt should have been used. The Assistant Director of Nurses concluded that the last transfer before the bruise was observed was this wheelchair-to-bed transfer, during which staff reported that a gait belt had not been used, in violation of facility policy and the resident’s plan of care.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.