Resident Injured After Use of Uninspected Broken Shower Chair
Penalty
Summary
A deficiency occurred when a resident with a history of stroke was injured after a fall from a broken shower chair. The incident took place while a CNA was providing a shower, and the chair collapsed, resulting in the resident sustaining rib fractures, a closed head injury, and a bruise. Prior to the incident, the shower chair had previously come apart during use, and two CNAs had reassembled it. The chair was then placed in the maintenance room, but no work order or clear communication regarding its condition was made. A review of facility records showed that required monthly inspections of shower chairs were not completed in 2024 or 2025. The maintenance lead found the chair in the boiler room without any note or work order and did not take further action. The same chair was later returned to use without proper inspection or repair, leading to the resident's fall and injuries. Staff interviews confirmed lapses in the process for identifying and removing unsafe equipment from service.