Failure to Promote Resident Dignity and Safety During Shower Chair Transport
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, mild intellectual disability, weakness, unsteadiness, and cognitive communication deficit was transported down the hallway in a shower chair after receiving a shower. The resident required substantial to maximal staff assistance for showering, dressing, toileting hygiene, and transfers, but did not require a mechanical lift. During transportation, the right front wheel of the shower chair detached after catching on a divot in the floor, causing the resident to fall forward and sustain a laceration above the right eye, which required emergency room evaluation and sutures. Staff interviews confirmed that the resident was not transferred via mechanical lift and that, at the time, some staff transported residents in shower chairs down the hallway, contrary to best practices. The facility did not have a policy regarding the transportation of residents in shower chairs down hallways, and staff were unaware that this practice was inappropriate unless a mechanical lift was required. The Indiana Nurse Aide Training Program Core Curriculum specifically states that residents should never be transported in a shower chair, emphasizing the importance of maintaining resident dignity and safety. The lack of adherence to these guidelines and the absence of a facility policy contributed to the incident and the resulting deficiency.