F0689

G

Failure to Provide Safe, Supervised Shower Gurney Care Resulting in Fall With Injury

Kingsville, Ohio Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify and implement comprehensive, individualized, and adequate fall-prevention interventions during shower care for a dependent resident using a shower gurney. The resident had moderate cognitive impairment, bilateral upper and lower extremity impairment, and was dependent on staff for toileting, hygiene, showers, transfers, dressing, and required substantial to maximum assistance with rolling left and right. Despite these needs, a quarterly fall risk assessment had determined the resident was not at risk for falls, noting forgetfulness, dependence on toileting checks and changes, and no prior fall history. On the day of the incident, the resident was transferred via mechanical lift by an LPN and an agency CNA from bed or chair to a shower gurney with both side rails up, and then transported without difficulty to the shower room.

Once in the shower room, the agency CNA was the only staff member present. She locked the gurney wheels and began preparing the resident for a shower by removing the incontinence brief and mechanical lift sling. She reported that she rolled the resident away from herself toward the stationary side rail in order to remove these items, while the resident remained in the center of the gurney. This action was taken despite the manufacturer’s written instructions for the shower gurney, which state that exaggerated user movement or rolling to the edge may cause the gurney to tip and specifically instruct caregivers not to roll a user away from themselves unless a partner caregiver is on the opposite side. The facility’s shower/tub bath policy did not address this manufacturer precaution and did not instruct staff to avoid rolling residents away from themselves on a gurney unless another caregiver was present on the opposite side.

During this one-person gurney shower setup, the resident fell from the gurney onto the floor. The CNA initially reported that a wheel came off the gurney, causing the fall, and staff arriving immediately afterward observed the resident on his right side on the floor next to the gurney, with the gurney slanted due to a wheel being off and the side rails in the up position. The resident had multiple abrasions, skin tears, bruising, and complained of pain. Subsequent hospital evaluation documented subdural collections/hemorrhage and septic shock. During interviews, the resident told his granddaughter and later surveyors that the aide had rolled him off the gurney, and facility staff, including the DON, LPN, and maintenance personnel, reported that reenactments and physical inspection of the gurney did not support the wheel-detachment explanation under normal use with body weight on the gurney. The facility’s internal investigation concluded that the fall most likely resulted from human error when the CNA rolled the resident too far while alone on the side opposite the stationary rail, contrary to the manufacturer’s instructions and without individualized, adequate supervision and fall-prevention measures during gurney shower care.

The incident and investigation also revealed that the facility’s existing policies and assessments did not adequately address the resident’s fall risk and the specific hazards associated with shower gurney use. The fall risk assessment had not identified the resident as at risk for falls despite his dependence for mobility and rolling, and the shower/tub bath policy lacked guidance on safe rolling techniques on a gurney and the need for a second staff member when rolling a resident away from the caregiver. Manufacturer instructions for the gurney, including the prohibition against rolling a user away from the caregiver without a partner on the opposite side, were not incorporated into facility procedures or staff practice at the time of the incident. As a result, the resident was left under the care of a single CNA who rolled him away from herself on the gurney, leading to the fall with injury.