Failure to Follow Two‑Person Bed‑Bath Care Plan Resulting in Repeat Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain accident‑prevention interventions and to follow an updated care plan for a resident with a prior fall and major injury. The resident had a history of a right closed hip fracture and displaced hip after falling from bed, and the facility’s practice and posted signage indicated that she required two‑person assistance and bed baths only. A sticker outside the resident’s room showed a two‑person assist requirement, and a sign above the bed stated “2 person bed baths only,” which the family confirmed was in place after the hip fracture. Despite this, the resident later reported being taken to the shower room, where staff pulled on her arm, after which she complained of shoulder pain. Record review showed that the resident’s care plan, revised after the hip fracture, documented that she was dependent on staff of two persons for bathing/showering three times per week as tolerated, with a cloth bed pad to be placed under her when bathing. This language was repeated in subsequent care plan entries, including after the humerus fracture. Bath documentation revealed inconsistent adherence to the care plan interventions: in the months following the hip fracture, the resident received a mix of bed baths and showers, with multiple entries marked as not available or refusals. Documentation showed that a shower was provided shortly before the resident reported to her daughter that she had been taken to the shower and that her arm had been pulled. Interviews further demonstrated a lack of alignment between the care plan, family preferences, and staff actions. The resident’s daughters reported that an X‑ray confirmed a left humerus fracture and that the resident described being brought to the shower and having her arm pulled. They also stated that the resident had complained of shoulder pain for two days before the X‑ray and that an LPN had been made aware. The MDS Coordinator stated she was unsure why the care plan had been updated to include baths/showers after the reported shoulder fracture and saw no clinical reason to prevent shower use, despite the family’s preference for bed baths. The Administrator and DON acknowledged that the family preferred bed baths and could not explain why the care plan was edited to allow showers after the second incident. The NP, who determined the fracture to be pathological based on osteopenia and lack of visible swelling or bruising, was not aware of the family’s bed‑bath‑only request, was unsure whether the resident had been taken to the shower, and confirmed that the injury could have been caused by pulling the resident’s arm.
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