Failure to Use Bath Chair Safety Straps and Provide Adequate Supervision During Bathing
Penalty
Summary
Staff failed to provide appropriate supervision and use of assistive devices for two residents who required assistance during bathing. Specifically, staff did not utilize the bath chair safety strap as required by facility policy, which states that safety belts must be used for bathing units and lifts to reduce the risk of injury. One resident, who had impaired balance, limited mobility, and required staff assistance for bathing and transfers, was not secured with the safety strap during a bath. As a result, the resident fell from the bath chair and sustained a left femoral neck (hip) fracture. The incident was confirmed through staff interviews, medical record review, and facility-reported incident documentation. Another resident, who was dependent on staff for bathing and required substantial assistance with transfers, was observed seated in a whirlpool tub with the safety strap not secured. The staff member present stated that the strap had been removed because the resident was sliding down in the chair and admitted to forgetting to reapply it. These actions were in direct violation of the facility's bathing policy and the expectation that the safety belt should always be secured when residents are in the bath chair. Additionally, after the fall, staff failed to perform a nursing assessment prior to moving or assisting the resident off the floor. Interviews with staff revealed inconsistencies in the use of the safety belt and the process followed after the fall. The lack of adherence to safety protocols and failure to assess the resident post-fall contributed to the deficiency identified by surveyors.