Based on record reviews and staff interviews, the facility failed to ensure residents were free from accidents or injury by failing to ensure staff utilize appropriate assistive devices during showers for 1 of 5 residents reviewed for accidents. This failure resulted in emergent care and injury to Resident #55. The findings include: Review of Resident #55's record revealed a nurse progress note dated 1/19/22 at 4:11 PM, indicating the resident had bleeding and was being sent to the hospital for evaluation and treatment, per the primary care provider instructions. The hospital record dated 1/19/22 at 5:03 PM, stated the resident presented with a vaginal laceration after a slip and fall on a shower chair. The resident sustained a laceration to the left side vaginal labia majora measuring 1.5 cm, requiring 3 sutures, and a superficial laceration to the external labia majora measuring 4 cm. Review of the facility investigation of the incident revealed a statement from Employee I, Certified Nursing Assistant (CNA) dated 1/19/22, which reported that Employee H, an agency CNA, came to her after she had showered Resident #55 and asked for help to get her out of the shower chair. When Employee I entered the room, she found Resident #55 stuck in the shower chair seat. Employee I and two other staff assisted to release Resident #55 from the shower chair. One of the resident's legs had slipped and was lodged between the opening in the middle of the chair and the arm rest on the side of the chair. They were able to get the resident out of the chair. The Director of Nursing (DON) provided an additional investigation document, which stated on 1/19/22, Employee H, CNA, placed Resident #55 in a shower chair and performed a shower. After the shower, Employee H noticed the resident was stuck in the seat of the shower chair. Employee H requested the assistance of Employee I to remove the resident from the chair. Once the resident was removed from the chair, the staff noted she was bleeding. The staff alerted the nurse. The resident was transferred to the hospital for evaluation. The facility was unable to provide any other evidence of an investigation for the incident. Further review of the medical record for Resident #55 revealed a care plan dated 3/25/22, stating resident observed with vaginal laceration during transfer with bath. The care plan interventions included administer antibiotic as ordered, administer pain medications as indicated, keep vaginal area clean and leave sutures in place, sutures are dissolvable, monitor vaginal area every day for signs of infection and follow up with physician as indicated. The record did not describe the incident causing the vaginal laceration. The care plan nor the task menu items described the proper assistive device staff should use to safely shower the resident. The resident's weight was 171 pounds on 1/1/22. The resident's medical diagnoses included multiple sclerosis and flaccid (limp) hemiplegia (partial paralysis) affecting the left non-dominant side. An interview was conducted with the DON on 5/24/22 at 4:23 PM. She stated the agency staff did not know the shower bed would have been a better assistive device to use for showering Resident #55. The resident's care plan nor the task menu listed the shower bed was to be used. A telephone interview was conducted with Employee H, CNA, on 5/26/22 at 9:57 AM. Employee H stated, according to a verbal report from staff, the resident was permitted to use a shower chair. She reported that on 1/19/22, herself and another staff transferred Resident #55 to the shower chair. She showered the resident. She took the resident back to her room in the shower chair. She stated the resident moved in the shower chair which caused her groin area to get stuck under the seat of the shower chair. The resident was stuck in the chair. She obtained assistance from other staff to remove the resident from the chair. The resident verbalized she was in pain. She stated she did not see anything wrong with the shower chair. She was not aware of any written information to inform staff of the proper assistive device (shower chair or shower bed) to use when showering residents. An interview was conducted with Employee I, CNA, on 5/26/22 at 10:22 AM. She confirmed she assisted Employee H to get Resident #55 out of the shower chair on 1/19/22. She stated the resident's buttocks was stuck in the chair and her leg was stuck between the plastic in the middle of the chair. The resident is like spaghetti and does not have much control of her extremities. She stated she would not use the shower chair for Resident #55; she would use the shower bed. An interview was conducted with the Director of Rehabilitation on 5/26/22 at 11:32 AM. She stated Resident #55 was last seen by therapy in November 2021 for wheelchair positioning. The resident has multiple sclerosis with fixed positions, leaning to her side, and poor trunk control. She stated the facility has never requested a therapy evaluation to determine the safest device to shower the resident. An interview was conducted with Employee J, CNA, on 5/26/22 at 11:46 AM. She stated she provides care to Resident #55. The resident has limp upper and lower extremities. She stated the shower bed is safer to use for the resident because her body is limp, and she would lean over in the chair. She reviewed the resident's electronic record and confirmed the record did not indicate what device to use during resident showers. An interview was conducted with Employee K, CNA, on 5/26/22 at 12:07 PM. Employee K stated she cares for Resident #55. She stated the resident does not have good control of her limbs and body, and she leans. She uses the shower bed to shower Resident #55. She stated neither the care plan nor the task menu instruct which device to use during a shower. Agency staff ask other staff which device to use for showers. A policy regarding accident prevention was requested on 5/26/22 at approximately 1:00 PM. At the time of survey exit on 5/26/22 at approximately 3:30 PM, the policy had not been provided.

Based on record review, staff interviews and policy review, the facility failed to thoroughly investigate an accident resulting in injury and failed to develop and implement appropriate action plans to address the cause of the accident for 1 of 5 residents sampled for accidents. (Resident #55) The findings include: Review of Resident #55's record revealed a progress note dated 1/19/22 at 4:11 PM, indicating the resident had bleeding and was being sent to the hospital for evaluation and treatment, per the primary care provider instructions. The record revealed a care plan last reviewed 3/25/22 stating resident observed with vaginal laceration during transfer with bath. The care plan interventions stated administer antibiotic as ordered, administer pain medications as indicated, keep vaginal area clean and leave sutures in place, sutures are dissolvable, monitor vaginal area every day for signs of infection, and follow up with physician as indicated. The hospital record dated 1/19/22 5:03 PM, stated the resident presented with a vaginal laceration after a slip and fall on a shower chair. The resident sustained a laceration to the left side vaginal labia majora measuring 1.5 cm, requiring 3 sutures, and a superficial laceration to the external labia majora measuring 4 cm. The record did not describe the incident causing the vaginal laceration. Neither the care plan nor the task menu items described the proper assistive device staff should use to safely shower the resident. The resident's weight was 171 pounds on 1/1/22. The resident's medical diagnoses included multiple sclerosis and flaccid (limp) hemiplegia (partial paralysis) affecting the left non-dominant side. Review of the facility's internal investigation of the incident revealed a statement from Employee I, Certified Nursing Assistant (CNA) dated 1/19/22 who reported that Employee H, an agency CNA, came to her after showering Resident #55 and asked for help getting her out of the shower chair. When Employee I, CNA, entered the room, she found Resident #55 stuck in the shower chair seat. Employee I and two other staff assisted to release Resident #55 from the shower chair. One of the resident's legs had slipped and was lodged between the opening in the middle of the chair and the arm rest on the side of the chair. They were able to get the resident out of the chair. The Director of Nursing (DON) provided an additional investigation document which stated that on 1/19/22, Employee H, CNA, placed Resident #55 in a shower chair and performed a shower. After the shower, Employee H noticed the resident was stuck in the seat of the shower chair. Employee H requested the assistance of Employee I to remove the resident from the chair. Once the resident was removed from the chair, the staff noted she was bleeding. The staff alerted the nurse. The resident was transferred to the hospital for evaluation. The facility was unable to provide any other evidence of an investigation for the incident. An interview was conducted with the Administrator on 5/24/22 at 4:19 PM. He stated the shower chair used for Resident #55 broke and she fell inside the chair. He stated he purchased a new chair and removed the old chair from service. When asked why the facility did not document a thorough investigation of the incident on 1/19/22 involving Resident #55, he stated he was on vacation when the incident occurred. A follow-up interview was conducted with the Administrator on 5/25/22 at 9:45 AM. He then stated the shower chair used on 1/19/22 for Resident #55 was not broken or in disrepair. An interview was conducted with the DON on 5/24/22 at 4:23 PM. She stated the agency staff did not know the shower bed would have been a better assistive device to use for showering Resident #55. Neither tthe resident's care plan nor the task menu indicated the shower bed was to be used. A follow-up interview was conducted with the DON on 5/26/22 at 2:41 PM. She confirmed that if Resident #55 had been showered in the shower bed, the incident would not have occurred. A telephone interview was conducted with Employee H, CNA, on 5/26/22 at 9:57 AM. Employee H stated, according to a verbal report from staff, the resident was permitted to use a shower chair. She reported that on 1/19/22, herself and another staff transferred Resident #55 to the shower chair. She showered the resident. She took the resident back to her room in the shower chair. She stated the resident moved in the shower chair which caused her groin area to get stuck under the seat of the shower chair. The resident was stuck in the chair. She obtained assistance from other staff to remove the resident from the chair. The resident verbalized she was in pain. She stated she did not see anything wrong with the shower chair. She was not aware of any written information to instruct staff on the proper assistive device (shower chair or shower bed) to use when showering residents. An interview was conducted with Employee I, CNA, on 5/26/22 at 10:22 AM. She confirmed she assisted Employee H to get resident #55 out of the shower chair on 1/19/22. She stated the resident's buttocks was stuck in the chair and her leg was stuck between the plastic in the middle of the chair. The resident is like spaghetti and does not have much control of her extremities. She stated she would not use shower chair for Resident #55; she would use the shower bed. An interview was conducted with the Director of Rehabilitation on 5/26/22 at 11:32 AM. She stated Resident #55 was last seen by therapy in November 2021 for wheelchair positioning. The resident has multiple sclerosis with fixed positions, leaning to her side, and poor trunk control. She stated the facility has never requested a therapy evaluation to determine the safest device to shower the resident. An interview was conducted with Employee J, CNA, on 5/26/22 at 11:46 AM. She stated she provides care to Resident #55. The resident has limp upper and lower extremities. She stated the shower bed is safer to use for the resident because her body is limp, and she would lean over in the chair. She reviewed the resident's electronic record and confirmed the record did not indicate what device to use during resident showers. An interview was conducted with Employee K, CNA, on 5/26/22 at 12:07 PM. Employee K stated she cares for Resident #55. She stated the resident does not have good control of her limbs and body, and she leans. She uses the shower bed to shower Resident #55. She stated neither the care plan nor the task menu indicate which device to use during a shower. Agency staff ask other staff which device to use for showers. A follow-up interview was conducted with the Administrator on 5/26/22 at 12:59 PM. He stated he needs to do a better job of ensuring agency staff know the residents. He should have documented more of the investigation interviews. He confirmed the facility still employs agency certified nursing assistants who provide baths/showers to residents in the facility. He did not know if there was information to inform staff about how to safely shower residents, but stated it should be listed on the tasks or care plan. He confirmed that relying on staff to inform agency staff how to shower residents is not a good process to ensure resident safety. On 5/26/22 at 2:32 PM, the Administrator stated the facility did not develop a quality assurance performance improvement plan related to the incident involving Resident #55. Review of the facility's undated policy regarding incidents and accidents revealed it is the policy of this facility for staff to utilize Electronic Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. The purpose of incident reporting can include: assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care, ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences, alert risk management and/or administration of occurrences that could result in claims or further reporting requirements.