Failure to Ensure Shower Gurney Brakes Functioned Properly During Resident Transfer
Penalty
Summary
The facility failed to ensure that the shower gurney's wheel brakes were locking properly, resulting in an accident during the transfer and bathing of a resident who was dependent on staff for all transfers and showers. The resident, who had acute respiratory failure, contractures of both lower extremities, and no discernible consciousness, was being transferred from bed to a shower gurney by a CNA and a respiratory therapist. During the transfer, the gurney's brakes did not lock properly, causing the gurney to slip away and the resident to slide to the floor. Staff present managed to prevent the resident's head from hitting the floor, but the resident's buttocks and legs did make contact with the floor. Interviews with the CNA and respiratory therapist confirmed that they were aware the gurney's brakes were not functioning correctly at the time of use. The CNA acknowledged that she should not have used the malfunctioning equipment and should have reported the issue to the charge nurse. The DON stated that staff are expected to immediately report malfunctioning equipment and remove it from service, but was not informed of the issue until after the incident. Facility policy requires that any equipment suspected of malfunctioning be removed from service and reported, but this procedure was not followed in this case.