Failure to Use Gait Belt During Assisted Transfer
Penalty
Summary
A deficiency occurred when staff failed to use a gait belt during a transfer for one resident who required assistance with activities of daily living due to impaired balance. The resident’s care plan, dated 12/24/25, specified that she required one staff member to assist with transfers using a gait belt. The facility’s gait belt policy directed staff to always use a gait belt for one- and two-person transfers and to never lift a resident under the arms (“chicken wing”). A grievance form dated 2/10/26 documented that the resident reported being upset that CNAs on the third shift lifted her by her arms instead of using a gait belt, although she did not sustain any injuries. During interviews, the physical therapy assistant confirmed that a gait belt should be used for one- or two-person assists because a resident could lose their balance, and the administrator acknowledged that a third-shift CNA had held the resident under her arms rather than using a gait belt, stating that the CNA should have used the gait belt for the safety of the resident and staff. The resident’s diagnoses included influenza, COPD, type 2 DM, asthma, HTN, low back pain, hyperlipidemia, obstructive sleep apnea, weakness, acute bronchitis, schizoaffective disorder, hypo-osmolality and hyponatremia, osteoarthritis, bipolar disorder, anxiety disorder, and depression. This combination of a documented care plan requirement, a facility policy mandating gait belt use, and staff acknowledgment that the transfer was performed by lifting under the resident’s arms instead of using a gait belt formed the basis of the cited deficiency related to accident hazards and inadequate supervision to prevent accidents.
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