Failure to Provide Adequate Supervision and Assistance During Resident Bathing
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance to a resident during bathing activities. The resident, who had a diagnosis of syncope and collapse and was coded as dependent for transfers on the Minimum Data Set (MDS), was observed being transferred from a rolling shower chair to a wheelchair by a single CNA. During the process, the resident was visibly weak, with shaking arms, and was required to stand twice without additional staff present. The CNA did not seek help despite the resident's instability and did not use the call light, citing concerns about response time and the presence of a surveyor. The CNA also admitted to making transfer decisions based on observation rather than the care plan or Kardex instructions. Interviews with the CNA and the Director of Nursing (DON) confirmed that the resident required more assistance than was provided and that proper protocols for transfer and supervision were not followed. The DON stated that both the care plan and the CNA Kardex contained clear guidance on transfer status, which was not adhered to during the incident. The failure to follow established procedures and to seek appropriate assistance placed the resident at risk for accidents or injury during the bathing process.