F0689

J

Failure to Prevent Accident Due to Inadequate Supervision and Unsafe Equipment for Pediatric Resident

North Hollywood, California Survey Completed on 11-08-2025

Penalty

No penalty information released

Summary

A two-year-old pediatric resident with severely impaired cognition, chronic respiratory failure with tracheostomy, ventilator dependence, and a history of liver transplant was admitted to the facility. The resident was dependent on staff for all activities of daily living and had a documented high risk for falls, with care plans and assessments indicating the need for frequent visual checks and not being left unattended. Despite these documented needs, the facility failed to ensure the resident remained free from accident hazards during bathing.

On the day of the incident, a Certified Nursing Assistant (CNA) transferred the resident from a crib to an adult-sized shower bed, which had significant gaps in the side rails. The CNA raised the side rails but then turned her back on the resident to retrieve a bed sheet, leaving the resident unattended. During this time, the resident slipped through the gap in the shower bed rail and fell to the floor, sustaining a bruise on the right cheek. The CNA did not request assistance from the Registered Nurse (RN) present in the room, nor did she maintain physical contact or line of sight with the resident as required by facility policy and the equipment manufacturer's instructions.

The facility had not completed an assessment to determine the safety of using adult-sized shower beds for pediatric residents and did not provide size-appropriate equipment. The facility's annual assessment and relevant policies did not address the need for pediatric-sized shower beds, and the resident's fall risk assessment was not updated after the incident. Staff interviews confirmed that the use of adult-sized shower beds for pediatric residents was standard practice, and that the risks associated with the equipment had not been adequately addressed or mitigated.

Removal Plan

• RN 3 assessed Resident 1 for any injuries and transferred to the GACH for further evaluation and was readmitted back at the facility.
• The PNM and RN 2 provided an in-service to CNA 1 regarding Patient Safety Prevention of Falls During Shower and Bathing Procedures.
• The IP revised the P&P titled, Status Post Falls/ Accident, to require an immediate post-fall IDT meeting and a care plan/risk assessment revision within 24 hours of any fall.
• The PNM and SDC started an in-service regarding Shower Beds/ Flexi Bath/ Bed Baths/ Grooming/ Falls/ Infection Control Reminders to all pediatric clinical staff including CNA 1 to not leave residents unattended and ensure residents remain in line of sight when providing bath/shower.
• Use of size-appropriate pediatric shower bed for pediatric resident with weight of less than 50 pounds. The PNM and the Infection Preventionist (IP) approved the new pediatric shower bed to ensure appropriateness for pediatric use.
• The SDC provided in-services regarding Shower Beds/Flexi Bath/ Bed Baths/ Grooming/Falls/Infection Control Reminders for pediatric licensed nurses and CNAs. The in-services required that all pediatric residents must never be left unattended/out of line of sight during bathing/showering or while on assistive devices (pediatric shower beds). The in-services included the updated P&P titled, Use of Shower Bed, and hands-on competency validation for pediatric transfers and the proper use of the new pediatric shower beds. The PNM, RN 1 and RN 2 will perform the quality and safety checks when the new pediatric shower beds arrive. Any new pediatric staff and pediatric staff on leave will receive the in-services and policies regarding pediatric equipment and bathing safety prior to giving shift baths/showers.
• The facility stopped the use of standard-sized shower beds for pediatric residents under 50 lbs.
• The facility purchased size-appropriate pediatric shower beds to be used for all pediatric residents.
• RN 1 and RN 2 provided a mandatory re-education regarding the topic Bathing Safety and Demonstration and P&Ps titled, Falls Prevention, Precautions, and Assessment, and Use of Shower Bed, on proper bathing and safety.
• RN 1 and RN 2 verbally notified staff during the beginning of each shift huddles that no pediatric residents under 50 lbs. were bathed on the standard (adult) sized shower beds.
• The IP updated the P&P titled, Use of Shower Bed, to ensure residents below 50 lbs. are not bathed/showered in standard (adult) shower bed. Residents under 50 lbs. will be showered in the pediatric-sized shower beds when they arrive. Before the arrival of the pediatric-sized shower beds, all pediatric residents less than 50 lbs. are to be given bed baths in their respective beds.
• The facility's leadership team conducted a Root Cause Analysis (RCA) to determine the cause of the deficient practice.
• The IP updated the P&P titled, Use of Shower Bed to include Resident is to always stay in line of sight of the CNA performing bath/shower. If at any moment the CNA needs to leave the resident's side during bath/shower, the CNA is to ensure there is coverage by a clinical staff member.
• The SDC, the PNM, and RN 2 in-serviced CNA 2 regarding Bathing Safety Demonstration with a return demonstration.
• The Interdisciplinary Team (IDT) reviewed and revised Resident 1's comprehensive care plan and Fall Risk Assessment. The updated plan of care included:
• The DON and RN 2 evaluated all 33 pediatric residents for potential risk for falls from the adult size shower bed. Seven (Residents 1, 3, 4, 5, 6, 7, and 8) out of 33 residents were identified at risk for falls during bathing.
• The DON and RN 2 completed evaluations for potential risk for falls from a shower bed for all 33 pediatric residents that included: a review of each resident's current Fall Risk Assessment and comprehensive care plan to ensure bathing procedures are followed, supervision needs are met, and the required bathing equipment is used; the PNM and IP performing a physical inspection and assessment of all bathing equipment used for each pediatric resident to ensure proper sizing and safety; RN 1 and RN 2 completing care plan updates for any pediatric resident requiring changes to bathing procedures and bathing equipment.
• The SDC, the PNM, RN 1 and RN 2 will be responsible for daily unit supervision and monitoring effectiveness. The SDC or Unit Charge Nurses will conduct random observational audits to ensure: only size-appropriate equipment is used for pediatric residents; care-planned bathing procedures and supervision levels are consistently followed; no pediatric resident is left unattended on any assistive device; staff can verbalize understanding of the new and revised policies.
• The SDC will report audit findings to the DON weekly and to the Quality Assurance and Performance Improvement (QAPI) committee monthly. The QAPI committee will review the data, analyze trends, and make recommendations for further action as needed. The QAPI committee will monitor on an ongoing basis until sustained compliance is achieved for three consecutive months.