Federal inspectors found staff transferring residents without gait belts during a September complaint investigation. The facility's policy, revised in June 2020, explicitly requires staff to use gait belts or mechanical lifts for all residents who need transfer assistance.
The Director of Nursing told inspectors during a September 24 interview that his expectation was clear: staff should use gait belts with all transfers. He identified the risks of not following this protocol as falls, injuries to both residents and staff, and skin problems.
"Staff had been in-serviced on safe transfers and the use of gait belts with all transfers unless contraindicated," the director told inspectors at 12:49 PM that day.
One resident involved in the violations had no medical restrictions preventing gait belt use, according to the director's statement to inspectors.
The facility's transfer policy runs nearly 500 words and includes detailed, step-by-step instructions for safe resident movement. The policy states its purpose as providing "the form of transfer best suited to the residents' needs and to maintain resident safety during the procedure."
According to facility rules, licensed nurses and rehabilitation directors must assess each resident's transfer needs and record the required procedure in care plans. The policy mandates that "residents must be lifted or transferred according to the determined procedure."
For residents requiring transfer assistance, the policy is unambiguous: they "will be transferred using a gait/transfer belt or with a lift." The document specifies that mechanical lifts must be used for any resident unable to independently pivot or transfer.
The facility's written procedures for two-person assisted transfers include 16 detailed steps. Step six specifically addresses gait belt application: staff "may apply gait belt (unless contraindicate) around residents' waist securely enough to prevent sliding up over ribs."
The procedure requires each staff member to stand facing the resident, one on either side, and "grasp the gait belt firmly" with specific hand positioning. Staff must instruct residents to hold onto their upper arms while using the belt to "draw the resident gently but firmly forward and upward to a standing position."
The policy emphasizes proper body mechanics and requires nursing staff training on "knowing the proper procedures and properly operating assistive devices."
Despite these detailed requirements and training, inspectors documented that staff were not following the established transfer protocols.
The violations occurred during what federal records classify as a complaint investigation, suggesting someone reported concerns about resident care or safety to state authorities.
Federal inspectors rated this violation as causing "minimal harm or potential for actual harm" and affecting "few" residents. However, the consequences of improper transfers can be severe, particularly for elderly residents whose bones may be more fragile.
The inspection findings highlight a gap between written policies and actual practice at the 675817-licensed facility. While the nursing director expressed clear expectations about gait belt use and acknowledged staff had received appropriate training, the reality on the floor differed from these standards.
Transfer-related injuries represent a significant risk in nursing homes, where residents often have mobility limitations, balance problems, or cognitive impairments that increase fall risk. Gait belts provide crucial stability and control during the vulnerable moments when residents move between beds, chairs, and wheelchairs.
The facility's policy recognizes these risks explicitly, noting that proper transfers maintain "resident safety during the procedure" and prevent injuries to both residents and the staff assisting them.
The September inspection revealed that despite comprehensive policies, mandatory training, and clear expectations from nursing leadership, basic safety protocols were not being followed when moving vulnerable residents.
This breakdown in following established safety procedures puts residents at risk for the exact injuries the policies were designed to prevent: falls, broken bones, and other transfer-related trauma that can significantly impact quality of life for elderly nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ft Worth Southwest Nursing Center from 2025-11-24 including all violations, facility responses, and corrective action plans.
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