Failure to Secure Safety Mechanisms During Bathing Results in Resident Fall and Injuries
Penalty
Summary
A deficiency occurred when a nurse aide failed to properly secure the safety mechanisms of a whirlpool chair, resulting in a resident falling forward from the chair and sustaining multiple injuries. The resident, who had severe cognitive impairment and required maximal assistance for bathing and transfers, was found face down and wet in the empty whirlpool tub by nursing staff. The safety features of the chair, including a seatbelt and locking safety bars, were not properly engaged at the time of the incident, as confirmed by a re-enactment conducted by licensed staff. The nurse aide involved was unable to provide a clear account of the events leading up to the fall and only stated that the incident happened quickly. The resident involved had significant medical conditions, including Alzheimer's disease, dementia with psychotic disturbances, anxiety, psychosis, chronic atrial fibrillation, and chronic heart failure. The resident's clinical record indicated a need for substantial or maximal assistance with bathing and transfers, and a BIMS score reflecting severe cognitive impairment and inability to direct care. After the fall, the resident was assessed and found to have a hematoma to the forehead, abrasions to the left knee and fifth toe, and bruises to both calves, but did not report pain or discomfort and did not require pain medication. Facility documentation and staff interviews confirmed that the nurse aide had received training on whirlpool safety and had demonstrated the required technique prior to the incident. However, the investigation determined that the aide failed to follow established procedures and the resident's care plan, resulting in the resident's fall and injuries. The facility substantiated the occurrence of neglect based on these findings.