Fall from Rolling Shower Chair Due to Improper Handling at Doorway Transition
Penalty
Summary
The facility failed to ensure safe use of bathing equipment and adequate supervision during transport in a rolling shower chair, resulting in a fall for one resident. The resident, admitted with diagnoses including spinal stenosis and chronic kidney disease, had a care plan indicating a need for partial to moderate assistance with bathing and bathing transfers. On the date of the incident, a NA student assisted the resident back to their room in a rolling shower chair. As they attempted to cross the transition strip at the doorway, the shower chair became stuck. The resident informed the NA student that they were usually assisted into the room backwards because of the transition strip. The NA student attempted to dislodge the stuck wheel by lifting up on the backrest of the rolling shower chair, causing the backrest to detach and the resident to fall backwards onto the floor. The resident recalled falling out of the shower chair and reported feeling afraid immediately after the incident. Staff, including an RN and the shower aide, assessed the resident after the fall and noted no major injury, with the resident able to stand and walk to bed, though minimal increase in back pain was reported. The DNS confirmed that the fall occurred due to incorrect and unsafe techniques used by the NA student when handling the rolling shower chair at the doorway transition strip.
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