Failure to Provide Adequate Supervision During Bathing
Penalty
Summary
The facility failed to provide adequate supervision during bathing for one resident, resulting in a deficiency related to accident hazards and supervision. According to facility policy, staff are required to remain with residents at all times during bathing, ensure all safety mechanisms such as seatbelts and locked wheels are in use, and never leave a resident unattended. However, a resident with diagnoses including high blood pressure, arthritis, and schizophrenia, who was cognitively intact and required assistance with activities of daily living, was left alone in a bath chair by an agency nurse aide who was unfamiliar with the equipment and procedures. The incident occurred when the resident was placed in the tub by the agency nurse aide, who then left the room immediately after asking the resident how the machine worked. The resident was found by staff after yelling for help, sliding down in the bath chair with water up to the collarbone/neck, the safety belt unfastened, the handlebar not in place, and the chair wheels unlocked. The resident reported feeling terrified during the incident and estimated being left alone for about ten minutes. The resident denied going under the water and was assessed with stable vital signs and no injuries following the event. Facility documentation and staff interviews confirmed that the agency nurse aide had not been trained on the use of the bathing equipment and that the resident was left unsupervised in violation of facility policy and federal regulations. The deficiency was identified through review of facility records, policies, and interviews, which established that the required supervision and safety measures were not provided during the resident's bath.