Failure to Educate Resident on Risks of Not Using Whirlpool Chair Safety Belt
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to use of a whirlpool tub chair safety belt. The facility had prior South Dakota Department of Health facility-reported incidents in which two residents fell when staff did not correctly use an assistive or safety device, including a whirlpool chair safety strap. The provider’s own Bath Chair Safety education stated that all residents are to use the bath chair strap unless the care plan reflects a refusal, and the whirlpool tub manufacturer’s manual required that all residents must always be securely safety belted at the waist when using the lift systems, warning that failure to secure the resident properly could result in injury. The resident at issue was admitted with diagnoses including Parkinson’s disease, diabetes, osteoarthritis, degenerative joint disease of the neck, and a history of an L2 compression fracture and falls. Her care plan documented that she was offered the whirlpool tub chair safety belt but may or may not use it, and she had hand tremors. Her BIMS score of 14 indicated intact cognition. There was no documentation in the electronic medical record that she had been assessed as not requiring the safety belt, and no documentation that she had been educated on the risks and potential adverse outcomes of not using the whirlpool safety belt. Staff interviews and observations showed that, in practice, all residents used the whirlpool chair safety belt except this resident. A CNA reported that all residents wore the safety belt unless the care plan indicated it was not required. The resident stated she used the whirlpool tub chair without the safety belt and reported she was not really aware that she could fall by not using it. The DON and administrator stated that the resident chose not to wear the safety belt and that this decision was reflected in her care plan, and the DON reported she had provided education about safe use of the safety belt, but there was no documentation of this education in the resident’s record, despite the manufacturer’s instructions that all residents must always be securely belted when using the whirlpool chair.
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