OWENSBORO, KY-SIGNATURE HEALTHCARE AT HILLCREST

Based on interview, record review, facility policy review, and manufacturer guideline review, it was
determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision and assistance to prevent accidents.

On [DATE], Resident #1 fell from a shower bed (gurney) while being assisted by one (1) Certified Nursing Assistant (CNA) during a shower, requiring Resident #1 to be transferred to an acute care facility for evaluation and treatment. Resident #1’s fall from the shower bed (gurney) resulted in a six (6) centimeter long scalp laceration that required nine (9) staples, a Subdural Hematoma, and a Closed Bicondyle Fracture of the Right Femur.

Review of Resident #1’s Activities of Daily Living (ADL) Care Plan, dated [DATE], revealed the facility addressed the resident’s need for assistance with activities of daily living to include bathing. However, the facility had not addressed the use of the shower bed or the amount of staff assistance needed to ensure the resident’s safety per the MDS assessed need. In addition, the facility had not addressed safety concerns with the shower bed use, after the resident’s fall from the shower bed on [DATE].

Review of Fall investigation, dated [DATE] at 12:55 AM, revealed Resident #1 was being showered in a shower bed by CNA #1, when the resident fell off the shower bed to the floor sustaining a scalp laceration that required nine (9) staples, a Subdural Hematoma, and a Closed Bicondyle Fracture of the Right Femur. The investigation revealed the resident required assistance of two staff while removing clothing and turning of the resident on the shower bed. It was also noted there were contributing factors of contracture’s and paralysis on Left side, and the resident kept the right side pulled up at the knee. Resident #1 had been determined to be at high risk for falls, and had impaired safety awareness. The Root Cause analysis of the fall was documented as resident required (2) two assist while removing clothing and turning on the shower gurney.

Review of a witness statement by RN #1, dated [DATE], revealed Resident #1 was assisted up with a mechanical lift by CNA #1 and RN#1, and placed in the shower bed (gurney) and taken to the shower room. RN #1 stated she was at the desk while CNA #1 was in the shower room showering Resident #1. The witness statement further revealed RN #1 stated CNA #1 had informed her when rolling the resident back a little, the rail went down, something from the bed fell and hit the floor, and Resident #1 fell to the floor.

Continued review of the witness statement revealed RN #1 stated she had gone into the shower room and applied pressure to the resident’s right forehead and the resident was lifted to the bed by the three (3) staff in the shower room, assisting the resident to the bed. RN #1 assessed Resident #1 who had complained of right leg and knee discomfort and a pressure dressing was applied to the forehead. Resident #1 was sent to the emergency room for evaluation.

Review of Emergency Department (ED) records dated [DATE], revealed Resident #1 presented to the ED after a fall, while getting a shower on a shower bed (gurney), when the equipment broke and the resident fell to the floor. The resident complained of right knee, head pain and was unsure if he/she lost consciousness. The resident also had nausea and vomiting. The ED record revealed Resident #1 had a head laceration of six (6) centimeters (cm) of the frontal scalp, which required repair with nine (9) staples, and swelling and tenderness of the right knee. Further review of the ED note, revealed Resident #1 had an acute fracture of the distal right femoral metaphysis. Resident #1 was admitted to the critical care unit, and treated for a fall, Subdural Hematoma, Closed Bicondylar fracture of right femur and Laceration of scalp without foreign body. The hospital discharged the resident on [DATE].

Interview with Administrator, on [DATE] at 8:54 AM, revealed there was no documentation of inspections of the shower beds prior to Resident #1’s fall. The Administrator stated faulty equipment was to be locked out and tagged out and removed from the building, right then by the individual finding it; so that no one would use it. Additionally, the Administrator stated he expected maintenance would follow the maintenance policy, and the TELS system direction, regarding maintenance care of the equipment, but there was no training for maintenance prior to the fall. Additionally, Administrator stated Maintenance was responsible to inspect the equipment. However, the facility provided manufacturer’s guidelines for shower bed 910, 915, and 920
models. However, the one that broke was a 1200 model, and root cause analysis of the fall was documented as resident required (2) two assist while removing clothing and turning on the shower gurney.