Failure to Provide Adequate Supervision and Accident Prevention During Shower Transfer
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents for a resident with severe cognitive impairment, dementia, and a history of syncope and muscle weakness. The resident required substantial assistance for bathing and was at high risk for falls, as documented in the care plan. During a shower, two CNAs were assisting the resident when one turned away to pick up a soap bottle, and the resident fell from the shower chair, sustaining a right femur fracture. Following the incident, there was inconsistency in staff reporting and documentation. CNA B reported that the resident had fallen to the floor, while CNA A denied a fall occurred. The incident was not documented in the facility's incident reports, and there was no Post-Incident Report (PIR) provided for the fall. The facility's investigation relied on CNA A's statement, and no further investigation was conducted into CNA B's account, despite her insistence that a fall had occurred. The Director of Nursing and the Administrator both acknowledged uncertainty regarding the circumstances of the injury and did not pursue a thorough investigation into the conflicting staff statements. The lack of documentation and failure to investigate the reported fall resulted in the facility not ensuring adequate supervision and accident prevention for the resident, as required by policy and regulatory standards.