Failure to Prevent Physical Abuse and Honor Refusal of Shower Leading to Leg Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to refuse care during a shower. The resident was an older adult with Alzheimer’s disease, bipolar disorder, dementia, and anxiety, who had been reported by her guardian as being in her normal state prior to the incident and without prior reports of a change in condition. On the day in question, the resident was scheduled for a shower. According to interviews and documentation, when CNAs entered the resident’s room with a mechanical lift and shower chair and placed the sling under her, the resident became combative, yelled that she was not supposed to receive a shower, and repeatedly stated she did not want the shower. Despite the resident’s repeated refusals, CNA F reported that she proceeded with the shower because RN H told her that the resident had to be showered or she would be written up, and that “no matter what” the resident was going to get a shower. Both CNAs described the resident as combative, digging into their skin, hitting, and kicking. CNA F stated she held the resident’s arms down by the wrists while CNA G washed the resident, and CNA G confirmed she saw CNA F holding the resident’s wrists to prevent the resident from hitting her. CNA G later stated that holding the resident’s wrists down and forcing the shower despite the resident’s refusal constituted abuse and that the shower should not have been given once the resident clearly refused. During the course of this forced shower, the resident sustained an injury to her right lower leg. Accounts from staff varied slightly, with CNA F and CNA G reporting that the resident kicked a bar on the wall in the shower room and/or the mechanical lift bar, and RN H reporting that the resident hit her leg on the mechanical lift bar when being transferred. Post-incident documentation by RN H described bruising, swelling, and an abrasion to the right shin, with swelling from the knee to the ankle, guarding of the leg, yelling out with touch, and refusal of range of motion of the knee. A progress note by the DON documented that the resident became aggressive during the shower and hit her leg on the shower chair, resulting in a bruise, and an X-ray subsequently showed an acute transverse fibular neck fracture of the lower leg. The resident’s guardian was notified of the bruise and told that the resident had been combative during the shower, and later learned of the resident’s death, which she described as a shock given that she had not been informed of any change in condition prior to that day.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.