Failure to Control Bed and Shower Equipment Hazards Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure the environment remained as free of accident hazards as possible and to provide adequate supervision and assistance devices, affecting two residents. One resident with dementia, muscle weakness, lack of coordination, and on daily warfarin had a room change and was later found with discoloration and bruising on the right forehead and eye. She reported bumping her head on the bed siderails/enabler bars. Her clinical record did not contain any assessment for safe use of enabler bars, no consent for their use, and no physician order authorizing them, despite her cognitive impairment and anticoagulant therapy. Subsequently, this resident was documented as unsteady on her feet, with non-reactive pupils and no response to physical stimuli, and she was sent to the emergency room for evaluation. The facility’s own incident report recorded that she had hit her head on the siderails and that she later returned from the hospital after testing. During interviews, the DON and Regional Director of Clinical Services confirmed there were no enabler assessments for this resident and acknowledged that the enablers were already on the bed after her move and should not have been there. These facts demonstrate that the resident’s environment included an unassessed and unauthorized enabler device that contributed to her head injury. Another resident with age-related osteoporosis, hypertension, and gait and mobility abnormalities sustained a fall in the shower room while attempting to transfer from a shower chair to a wheelchair. A staff member was present but was unable to stop the fall. The resident reported that as she stood up, the shower chair slid out, causing her to fall to the floor, later complaining of significant pain in the right hand, wrist, and forearm. Imaging showed scapholunate widening suggesting a ligamentous injury, and OT documentation noted severe pain and functional deficits requiring a wrist brace. The fall report and staff interview revealed that at the time of the fall only the front brakes of the shower chair were locked, the back brakes were not locked, and the aide assisting the resident admitted she forgot to lock the back brakes, despite the DON’s expectation that shower chair brakes be locked as appropriate.
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