Failure to Investigate Alleged Abuse and Injury During Forced Shower
Penalty
Summary
The deficiency involves the facility’s failure to investigate and report an alleged abuse incident and injury involving one resident. The resident was an older adult with Alzheimer’s disease, bipolar disorder, dementia, and anxiety, who later expired at the facility. According to staff interviews and documentation, two CNAs attempted to provide a shower using a mechanical lift and shower chair after being directed by an RN that the resident had to receive a shower. The resident repeatedly stated she did not want a shower and became combative, yelling, kicking, hitting, and digging into staff skin. During the shower process, the resident kicked a shower bar on the wall and/or the mechanical lift bar, and staff documented bruising to the right shin and fingertip bruising on the arms from efforts to control the resident’s movements. One CNA admitted to holding the resident’s wrists down while the other CNA washed the resident, and another CNA stated that forcing the resident to shower against her will and holding her wrists down constituted abuse and violated the resident’s rights. Subsequent nursing documentation and a written statement by the RN indicated the resident developed bruising, swelling, and an abrasion to the right shin, with swelling from the knee to the ankle, guarding of the leg, and yelling out with attempts at touch or range of motion. An X-ray later showed an acute transverse fibular neck fracture of the lower leg. The DON documented notifying the resident’s guardian about a bruise to the right shin and indicated the injury occurred when the resident hit her leg on the shower chair during aggression in the shower. Despite the documented injury, staff statements describing actions they considered abusive, and the resident’s expressed refusal of the shower, the facility did not provide an incident report or evidence of a thorough investigation when requested by surveyors. The report states that the facility did not perform an investigation regarding the incident.
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