Failure to Train CNAs on Safe Shower-Bed Positioning and Required Two-Person Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure CNAs had appropriate training and competencies in repositioning techniques and shower-bed care, which led to a resident rolling off a shower bed and sustaining injuries. The resident had a history of stroke with right-side hemiplegia, diabetes mellitus, diabetic retinopathy, dysarthria, aphasia, vascular dementia, and seizure disorder, and was totally dependent for bathing/showering per the MDS, requiring assistance of two or more staff. The resident’s care plan and Kardex both specified two-person assistance when showering and using the shower bed, and that the resident was totally dependent for transfers. Despite these documented needs, the resident reported being assisted by only one staff member during the shower when they rolled off the shower bed onto the floor. Surveyor interviews and record review showed that on the day of the incident, one CNA (CNA B) assisted another CNA (CNA C) only with the Hoyer lift transfer, then left, after CNA C declined further help with the shower. CNA C confirmed they were alone in the shower room while providing the shower. CNA C stated they rolled the resident onto their right side, away from themselves, to wash the resident’s bottom, and the resident “kept rolling,” ultimately falling from the shower bed to the floor. CNA C acknowledged that they obtain resident care information by reading the Kardex at the beginning of the shift and that they did not receive specific training on whether to roll residents toward or away from themselves during care, stating that their technique “depends on what I’m doing.” Further interviews with the Staff Development Coordinator and facility leadership revealed that staff did not receive classroom training on the use of shower beds, and the Staff Development Coordinator stated they did not provide training on bed mobility or positioning during showers/bed baths, believing it to be “common sense” and that CNAs should follow the Kardex. The ORMI/Annual Tracking Log for CNA in-services did not show training on bed mobility, Kardex training, or shower bed training. The DON acknowledged that, according to the MDS, care plan, and Kardex, two staff should have assisted with bathing and that the resident should have been rolled facing the CNA, consistent with facility policies on bed mobility and turning a dependent resident toward staff, which instruct staff to roll residents toward them. The facility did not have a specific policy for shower beds, and the DON and NHA were unable to provide evidence that the CNAs involved had been trained on shower bed use and proper positioning after the accident.
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