Improper Transfer Techniques and Lack of Gait Belt Use During Resident Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide safe transfers and adequate supervision for a cognitively impaired resident with a history of falls, gait abnormalities, muscle weakness, and lack of coordination. The resident’s MDS dated 01/25/2026 documented severe cognitive impairment with a BIMS score of 4/15 and a need for substantial/maximal assistance for bed mobility, sit-to-stand, and transfers to a wheelchair. The care plan dated 03/29/2025 indicated the resident required one-person assistance for transfers. Video and photo evidence from 02/14/2026 showed CNA A transferring the resident without a gait belt on multiple occasions. At approximately 5:01 p.m., CNA A placed the wheelchair at the bedside, pulled back the covers, and used her right hand to grab the resident’s left hand to pull her up to a sitting position without supporting the resident’s back, during which the resident screamed and appeared to grimace. The bed was not locked and rolled slightly during this process. The same video sequence showed CNA A grasping the resident’s upper right arm by the bicep area, adjusting the resident’s blouse, and then transferring the resident from the bed to the wheelchair without a gait belt, with both appearing to struggle and the resident being assisted into the wheelchair abruptly and appearing to cry. Later, around 5:12 p.m., the video showed CNA A returning the resident from the restroom to the bedside with the resident’s upper body covered but without a brief, leaving the resident’s private area exposed. CNA A then transferred the resident from the wheelchair back to the bed without using a gait belt. Interviews with the Director of Therapy and the DON confirmed that staff were expected to use gait belts for transfers and that failure to do so could result in falls or injury. The facility’s “Safe Resident Handling/Transfers” policy dated 02/19/2025 stated that all residents require safe handling when transferred and that handling aids may include gait belts, and that staff are expected to maintain compliance with safe handling/transfer practices, which was not followed in this case.
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