Failure to Use and Maintain Bath Chair Safety Belt Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from a fall during bathing activities by not ensuring proper use and maintenance of required safety equipment and adequate supervision. The resident reported falling in the shower after slipping off a shower chair and stated that only one staff member was present at the time. The CNA who provided care stated that the resident had been placed on the bath chair with assistance from another staff member, but that the second staff member did not remain for the whirlpool bath. The CNA reported that she placed the resident in the whirlpool tub while he was seated on the bath chair and, when she opened the tub door to assist him out, he slid off the chair and fell between the tub and the tub door onto his left hip. The CNA did not recall placing a safety belt on the resident and acknowledged that if a belt had been used, the fall likely would not have occurred. The resident also did not recall whether a safety belt had been in use. Further observations and interviews showed that the bath chair on the resident’s unit had only half of the black safety belt attached. The ADON stated that white safety straps had recently been placed on bath chairs because the previous ones were soiled, and denied prior knowledge that safety straps were missing or in disrepair. The maintenance staff member stated that he would replace safety straps if he received a work order or a request from nursing, but he did not recall receiving any such request, and no repair requests for the bath chair were documented on the unit’s maintenance repair log. The bath chair instruction manual specifies that all residents must always be securely belted at the waist when using the lift systems and warns that failure to secure the resident properly with the safety belt could result in injury. Facility policies on Preventative Maintenance Responsibilities and Fall Prevention and Management require maintaining a safe physical environment and ensuring the resident environment remains as free from accident hazards as possible, with adequate supervision and assistive devices to prevent accidents.
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