Resident Injury Due to Improper Use of Shower Chair on Incline
Penalty
Summary
A resident with a history of falls and fractures, who was dependent on staff for showers and required assistance from two staff members for transfers, sustained a fall with injury during a shower. The incident occurred when a nursing assistant attempted to pull the resident, seated in a shower chair, backwards up a pronounced incline into the shower stall. As the chair was pulled over the incline, the front wheels lifted off the ground, causing the chair to tip backwards. The staff member was unable to stabilize the resident due to the resident's weight, resulting in the resident being lowered to the ground as the back of the chair broke. The resident subsequently complained of pain and was found to have fractured ribs, requiring admission to the Trauma Intensive Care Unit. Surveyor observation confirmed that the entrance to the shower stall had a steep incline, and review of the shower chair manufacturer's manual indicated that the equipment should not be used on an incline and all casters should remain in contact with the floor. Staff interviews revealed that only one staff member was present during the transfer into the shower stall, despite the resident's care plan requiring two-person assistance. The facility's investigation and staff statements corroborated that improper use of the shower chair and inadequate supervision contributed to the accident, resulting in significant injury to the resident.