Failure to Use Gait Belt During Manual Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of required assistance devices during a manual transfer for one resident. The resident was an elderly female with dementia, severe cognitive impairment, short- and long-term memory problems, dysphagia, a history of falls (including two falls without injury and one with minor injury), anxiety disorder, and depression. Her MDS and care plan documented that she was dependent on staff for chair-to-bed transfers and most ADLs, and that she required total assistance by one staff member for transfers and other self-care tasks. On the observed date and time, a CNA assisted the resident from her wheelchair to her bed without using a gait belt. The CNA placed an arm around the resident’s chest area, pulled her to a standing position, pivoted her toward the bed, lowered her onto the bed, removed her shoes, and assisted her into a lying position. During this transfer, the resident was noted to be very unsteady and shaky, and she held onto the bed side rail while being assisted. No gait belt was applied at any point during the transfer, despite the resident’s documented dependence and history of falls. Interviews with therapy and nursing staff established that facility practice and training required use of a gait belt for residents needing one- or two-person manual transfers. The COTA stated that the resident required assistance of one staff for transfers and that staff should use a gait belt for her, and further stated that lifting under the arms or around the chest (bear hug technique) was not acceptable. Multiple CNAs and LVNs confirmed they were expected to use gait belts for manual transfers. The CNA who performed the transfer acknowledged she had been trained to use a gait belt, recognized she should have used one during the observed transfer, and admitted she instead used a bear hug technique. The facility’s written “Safe Lifting and Movement of Residents” policy required use of appropriate techniques and devices, and staff training in manual devices such as gait belts, confirming that the observed transfer did not follow established procedures.
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