Failure to Use Bath Chair Safety Belt Results in Resident Fall
Penalty
Summary
A certified nursing assistant (CNA) failed to use the safety belt on a whirlpool bath chair while bathing a resident who was totally dependent on staff for transfers and mobility. The resident, who had been admitted the previous day, was assisted into the bath chair using a full-body mechanical lift by two CNAs. After the bath, while the resident was still seated in the bath chair, the CNA wheeled the resident away from the tub without securing the safety belt, resulting in the resident sliding out of the chair and falling to the floor. The resident involved had multiple complex medical conditions, including sepsis, pneumonia, epilepsy, neuromuscular dysfunction of the bladder, restlessness, agitation, dysphagia, major depressive disorder, gastrostomy status, encephalopathy, Type 2 diabetes mellitus with neuropathy, aphagia, and acute respiratory failure with hypoxia. The resident was nonverbal at baseline and required total assistance for transfers and bed mobility, as documented in her care plan. At the time of the incident, the care plan specified two-person assistance for transfers but did not yet include specific interventions for bathing safety or the use of the bath chair safety belt. Interviews and observations revealed that, prior to the incident, it was not standard practice or policy at the facility to use the bath chair safety belt for all residents. The CNA involved in the incident was relatively new and did not secure the safety belt during the bath. Other staff confirmed that the use of the safety belt was not routinely enforced before the fall occurred. The safety belt was available and present in the whirlpool bath rooms, but its use was not consistently implemented.