Failure to Use Gait Belt During Transfer of High Fall-Risk Resident
Penalty
Summary
The deficiency involves staff failure to follow the facility’s gait belt policy during the transfer of a resident identified as being at risk for falls. The resident had multiple diagnoses, including a history of falling, polyosteoarthritis, other chronic pain, and hypertension. A fall risk assessment documented that the resident was at risk for falls, had an unsteady gait, and had experienced one to two falls in the prior three months. The resident’s fall care plan and ADL care plan, both initiated on the same date as the observation, identified a risk for falls and functional performance deficits due to weakness from a recent hospitalization, with interventions directing staff to assist the resident with ADL tasks as needed. On the morning of the observation, the resident was seated in a chair in their room when a CNA, who stated it was her first time assisting this newly admitted resident, prepared to transfer the resident from the chair to a wheelchair. The CNA positioned the wheelchair close to the resident’s chair and asked the resident to stand. The resident stood while the CNA held the resident’s hand to assist with the transfer. Although the CNA had a gait belt in her pants side pocket and acknowledged that CNAs are supposed to use a gait belt when assisting residents with transfers, she did not place the gait belt around the resident’s waist during this transfer. Later that day, the DON confirmed that CNAs are required to use a gait belt when transferring residents and that the CNA should have used a gait belt with this resident, consistent with the facility’s written policy stating that a gait belt will be used with weight-bearing residents who require hands-on assistance.
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