Failure to Follow Care Plan and Stop Shower When Resident Became Combative, Resulting in Injuries
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to follow the resident’s comprehensive care plan regarding resistance to care. The resident had diagnoses including unspecified dementia, chronic diastolic congestive heart failure, and chronic kidney disease, and the MDS documented that the resident was able to be understood, able to understand others, and had intact cognition. The resident’s care plan, initiated earlier, specified that when the resident became combative and agitated, staff were to leave the resident safe and reapproach later. Despite this, on the day of the incident, two CNAs continued to provide shower care after the resident became combative. During the shower, the resident became combative and began striking one of the CNAs. CNA #1 reported that they continued the shower, attempted to keep the resident from sliding off the shower chair, and tried to deflect some of the blows directed at CNA #2. The care was not stopped despite the resident’s combative behavior and the existing care plan intervention to leave and reapproach when the resident was combative. The facility’s own investigation later determined that there had been a violation of the comprehensive care plan. As a result of the continued showering while the resident was combative, the resident sustained multiple injuries. These included several skin tears on the left elbow and left forearm with surrounding bruising, a skin tear on the right elbow, scattered bruising to the right arm, a hematoma on the back of the head, a laceration on the back of the head below the hematoma, and bruising to the left ankle. The RN who assessed the resident documented these injuries in a progress note, and the former medical director later described the injuries as minor with no significant radiographic findings. The incident was reported to nursing staff after the shower was completed and the resident had been returned to the room.
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