Failure to Assess, Document, and Treat Resident Injury Following Shower Chair Accident
Penalty
Summary
Nursing staff failed to assess, document, and respond appropriately when a resident with hemiplegia, hemiparesis, and dysphagia experienced an accident while being transferred in a shower chair. The resident, who only speaks Hmong and is rarely understood, slipped into the opening of the shower chair, resulting in her right leg being caught and sustaining a cut on her right thigh. Despite the resident expressing pain verbally and through facial grimacing, there was no documentation of the incident or injury in the medical record, and no pain assessment or treatment was provided. Interviews with staff revealed that the CNA present during the incident observed the injury and pain but did not document the event. The DON and assigned nurses were either unaware of the incident or could not recall details, and no one completed a change in condition assessment or notified the physician as required by facility policy. The Medication Administration Record showed no pain medication was administered, and pain scores were recorded as zero following the incident. Additionally, the care plan was not updated to address the accident or injury. Family members confirmed being informed of the accident and noted the resident's complaints of pain. Observations days after the incident revealed visible scabbing and injury to the resident's right thigh. The Infection Preventionist acknowledged that the accident and injury were not addressed by nursing staff or the facility, indicating a failure to ensure staff had the competencies and skills necessary to provide appropriate care and documentation for the resident.