Resident Fall Due to Inadequate Supervision During Shower Chair Transport
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, including hemiplegia, muscle weakness, and a history of stroke, was transported in a reclining shower chair by a single nursing assistant. The resident required extensive assistance for mobility and transfers, as documented in clinical records and therapy notes, and was non-ambulatory, requiring a Hoyer lift with two staff for transfers. Despite these needs, the resident was moved alone in the shower chair, which did not have a seatbelt, and fell when the chair was pushed over a raised threshold, resulting in the resident hitting the back of their head. Interviews with staff revealed inconsistent knowledge and unclear policies regarding the number of staff required to transport residents in different types of shower chairs. Some staff believed two people were needed for certain chairs, especially for residents requiring a Hoyer lift, while others were unsure or could not specify requirements. The staff member involved in the incident acknowledged forgetting the two-person requirement and transported the resident alone, leading to the fall. Facility documentation and interviews indicated a lack of formal education or competency assessments regarding the use of shower chairs, except in response to incidents. The facility's bathing and grooming policy did not specify staff requirements for transporting residents in shower chairs, and the care card for the resident did not provide guidance for safe transport in the chair. This lack of clear procedures and staff training contributed to the unsafe transport and subsequent accident.