Failure to Provide Adequate Supervision During Shower Results in Resident Injury
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, severe vascular dementia with mood disturbances, agitation, psychotic disturbance, and lack of coordination was dependent on staff for transfers, showering, and bathing, and required two-person assistance for these activities according to the care plan. The care plan also noted the resident was combative and resistive to care. The resident had a BIMS score of 0, indicating severe cognitive impairment, and a history of fractures. On the morning of the incident, two staff members transferred the resident to a shower chair and brought the resident to the spa room. One staff member left the room, instructing the other to use the call bell if assistance was needed. The remaining staff member attempted to shower the resident alone. During the shower, the resident became combative, attempting to hit and bite the staff member. The staff member tried to distract the resident by handing over a washcloth, but the resident lunged at the staff member and fell out of the shower chair, striking their head against the wall. The resident sustained a large scalp laceration measuring 12x6 cm, which required 26 staples at the hospital. Staff statements and facility documentation confirmed that the care plan requiring two-person assistance during showers was not followed. The incident resulted in actual harm to the resident, who was sent to the emergency department for treatment. The Nursing Home Administrator confirmed that the resident was not appropriately supervised during care, leading to the injury.