Failure to Provide Two-Person Assist and Safe Positioning During Shower Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide the required two-person assistance during a shower and to safely reposition a dependent resident, resulting in a fall from a shower bed and injury. The resident had a history of right-side hemiplegia following a stroke, diabetes mellitus with diabetic retinopathy, dysarthria, aphasia, vascular dementia, and seizure disorder, and was unable to complete a BIMS interview. The resident’s MDS and care plan documented total dependence for showering/bathing and rolling in bed, with the need for assistance from two or more helpers, and the Kardex specified a two-person assist when showering and using the shower bed. Despite these documented needs, only one CNA provided the shower at the time of the incident. During the incident, two CNAs used a Hoyer lift to transfer the resident onto a shower bed, but only one CNA remained to perform the shower. The CNA who provided the shower reported that they were alone in the shower room and did not believe additional help was needed. While washing the resident, the CNA asked the resident to roll to the right side so the resident’s bottom could be washed and demonstrated rolling the resident away from their own body. The resident continued rolling and fell off the shower bed onto the shower floor. The LPN, who was not present during the shower, was called afterward and found the resident screaming and bleeding from the head, and emergency services were contacted. Post-incident observations and interviews further described the environment and staff practices that preceded the fall. The shower room had a narrow opening into the shower stall, with the shower bed only able to fit partway into the stall and a raised threshold at the entrance. The resident later reported having been on the shower bed, rolling over, and falling to the floor, and indicated ongoing pain in the right knee area. Staff interviews revealed that CNAs were expected to obtain care information from the Kardex and that there was no classroom training on the use of shower beds. The staff development coordinator stated that staff should roll residents toward themselves during care, and facility policies on bed mobility and turning a dependent resident directed staff to roll residents toward the staff member, but the CNA involved in the incident rolled the resident away from themselves while working alone, contrary to the resident’s documented need for two-person assistance.
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