**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility failed to ensure a shower bed was comprehensively inspected for safety or function by the Maintenance staff or by the CNA prior to its use, failed to ensure a resident was repositioned on a shower bed using two staff in accordance with the plan of care, and failed to ensure the resident was rolled toward the CNA providing care in accordance with the CNA training record for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B falling from a shower bed and sustaining a subdural hematoma with midline shift (a potentially fatal traumatic brain injury), a fracture of the left humerus (the largest bone of the upper extremity), and a facial laceration. The immediate jeopardy began on 08/05/24, when the facility failed to ensure a resident's safety during a shower when a CNA (Certified Nurse Aide) did not follow proper procedure guidelines while turning a resident in a shower bed. The facility did not assess the shower beds for safety per the manufacturer's instructions and the Maintenance Director altered the shower bed by replacing pipes and putting the device back into service after the fall. The Administrator, DON (Director of Nursing), and ADON (Assistant Director of Nursing) were notified of the Immediate Jeopardy on 08/08/24 at 6:44 P.M. Findings include: The clinical record for Resident B was reviewed on 08/08/24 at 9:29 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/21/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, hemiplegia (one-sided muscle paralysis or weakness), hypertension, renal insufficiency, diabetes, non-Alzheimer's dementia, seizure disorder, anxiety, and depression. The resident was dependent on staff for bathing/showering, upper body dressing, lower body dressing, personal hygiene, rolling left/right, and tub/shower transfers. The resident required extensive assistance of two staff members for bed mobility. The resident had impairment on one side of the upper and lower extremity. The resident had no falls prior to the assessment. The resident's Care Plans were reviewed on 08/08/24 at 11:26 A.M., and included a care plan, with a most recent revision date of 04/04/23, that indicated the resident had an ADL self-care performance deficit related to impaired cognition, left sided hemiplegia, dementia, and history of a left humerus fracture. The interventions included, but were not limited to the following: - An intervention, dated 05/16/23, that indicated the resident required the use of a mechanical lift for transfers with the assistance of two staff members. - An intervention, dated 12/21/21, that indicated the resident required extensive assistance of one staff member for showers. - An intervention, dated 12/21/21, that indicated the resident required extensive assistance of two staff members for bed mobility. A Progress Note, dated 08/05/24 at 2:40 P.M., indicated the resident was in the shower room for her shower. CNA (2) reported that during the shower the side rail to the shower bed gave out. The resident fell while in the shower room. The fall report, dated 08/05/24 at 2:45 P.M., indicated Resident B was in the shower room. It was reported by CNA (2) that during the resident's shower the side rail to the shower bed gave out and the resident fell. The resident was awake and talking to the nurse. She verbalized some understanding of the incident. She was noted to have a one-inch laceration with a hematoma (bruise) present above the right eye. There was a mechanical failure with the shower bed rail. The resident was sent to the local hospital. A Local Emergency Department Physician's Note, dated 08/05/24 at 5:22 P.M., indicated the resident had fallen approximately three feet, hit her elbow, and left shoulder, and had a laceration to her right eyebrow and right elbow. The resident had a history of a stroke with left-sided weakness. The CT (Computed Tomography) scan of the resident's head showed a large acute subdural hematoma (a pool of mostly clotted blood caused by a broken blood vessel). An acute hemorrhage was also seen. There was a midline shift of the septum (thin wall separating the left and right sides of the brain) by about six to seven millimeters. The left humerus (upper part of the arm) was fractured. A Trauma History and Physical, dated 08/05/24 through 08/06/24, indicated the resident had a right forehead laceration and was disoriented. The CT scan of the head without contrast indicated the resident had a large right-sided subdural hemorrhage with significant midline effect and probable subfalcine herniation (midline shift) with a critical result if significant intracranial hemorrhage. The known injuries were SDH (subdural hemorrhage) with midline shift and humerus fracture. A Trauma Attending assessment, dated 08/05/24 at 7:13 P.M., indicated the resident's injuries by exam and radiographic findings/plan indicated the resident had a TBI (Traumatic Brain Injury) with SDH and MLS (Midline Shift), neurosurgeon consulted and non-operation with poor prognosis, and a left humerus fracture with no intervention and given comfort care. A Trauma Attending Addendum Physician Note, dated 08/06/24 at 9:04 A.M., indicated the resident had a fall resulting in a severe TBI that was non-survivable and inoperable per the neurosurgeon. The resident was awaiting hospice and palliative care input. The resident died at the hospital on [DATE]. During an interview on 08/08/24 at 9:17 A.M., LPN (Licensed Practical Nurse) 3 indicated Resident B passed away early that morning. She had been told the resident had a fall in the shower on 08/05/24 and was sent out to the hospital. During an interview on 08/08/24 at 9:53 A.M., LPN 6, while the DON was present, indicated on the day of the incident, 08/05/24, CNA 2 was giving Resident B a shower. The CNA started yelling for help in the shower room. She went into the shower room and the resident had fallen off the shower bed on to the floor, on Wing 3. The CNA indicated the bed rail had gave way on the shower bed. CNA 2 was the only staff in the shower room at the time of the fall. When she first observed the resident, she was lying face down on the floor. The resident was assessed and not moved, and the DON came and sat with the resident while she went and called EMS (Emergency Medical Services) to transport the resident to the hospital. The resident was breathing and stable after the fall. She didn't show any signs of distress. There was a small amount of blood present. The resident was able to squeeze her hand and had a laceration above her eye. The resident was transported to a local hospital. The physician and family were notified. The DON indicated due to the small amount of blood, she had placed a small towel under the resident's head prior to EMS arriving. During an interview on 08/08/24 at 10:01 A.M., the DON indicated when she entered the shower room the resident had fallen off the right side of the shower bed. The right-side rail had given way. One of the pins to the shower bed was lying on top of the bed. She wasn't sure how the pin got on the top of the bed. The right side of the rail was down. The pins were not to be removed while the resident was being showered only before and after the shower to get the resident in and out of the bed. There wasn't a problem with the shower bed. The Maintenance Director and Administrator checked the bed after the incident and there wasn't a problem with the shower bed. CNA 2 was terminated due to the incident. During an interview on 08/08/24 at 10:11 A.M., CNA 2 indicated she was giving Resident B a shower on the shower bed in the shower room alone. She was standing on the left side of the shower bed and turned the resident to her (the resident's) right side to rinse the soap off the resident. She understood the rail would be enough to hold the resident. The right-side shower bed PVC (Polyvinyl chloride) rail broke close to where the pin went in. She was unsure if the bed was broken prior to the shower. She had only moved the left side rail of the shower bed when she placed the resident on it. She never removed the pins or checked the pins on the right side. The shower bed had two to three inch pins that went into the four corners of the shower bed. When the resident fell, she called for help right away. She was the only staff member in the shower room at the time of the fall. She was re-educated via the telephone on rolling a resident towards the caregiver's body when another staff member wasn't present. A shower bed on Wing 3 that was used at the time of the fall on 08/05/24 was observed with the Maintenance Director, on 08/08/24 at 10:24 A.M. The bed frame and railings were made of PVC (polyvinyl chloride) pipes. The bed lacked any identifying markers related to the weight limit. The bed was approximately three feet high, with rails on both sides that were approximately six inches high. A metal pin was attached at each of the four corners of the bed with a stiff plastic strip. The pins went into holes in the rails and held the rails in place. The Maintenance Director indicated staff would remove both pins on one side to lower the railing. He recently installed the plastic strips that attached the pins to the bed. Originally, there were thin black rubber strips that held the pins onto the bed, but they were easy to break. He was not in the facility when Resident B fell out of the shower bed, and he did not see the bed immediately after the incident. He was told after the incident that one of the four pins were found in the shower bed. The bed was taken out of service, and he took the bed outside and checked it for problems, there were none. He went through the bed and made sure no screws were cracked or missing. There were no documented routine checks on the beds, but staff would lose the pins a lot, so he did go around and check to make sure there were four pins in the beds. The shower bed was back in service and was used as needed. The shower bed on Wing 4 was observed with the Maintenance Director on 08/08/24 at 10:37 A.M. The shower bed was similar to the one on Wing 3, except there was a sticker at the foot of bed that identified it had a 500-pound weight capacity. The bed had the same white plastic strips holding the pins in place. The Maintenance Director indicated he had recently installed the white strips and replaced all four pins in that bed. The shower bed was in service and used as needed. During an interview on 08/08/24 at 10:45 A.M., Maintenance Staff 5 indicated on 08/05/24 a housekeeper had told him a resident had just had a fall. He went and looked at the shower bed to see what happened. The shower bed was brought out of the shower room. Each stationary corner of the bed, where the side rails connected in the upright position, contained solid rounded caps. One of the caps was off and missing. Where the cap was off, the PVC was broken. So, when the resident had rolled, the side rail gave way, and the resident fell to the floor. There wasn't enough plastic on the stationary corner to hold the pin in place. The maintenance didn't have routine checks on the shower beds. They would just take a quick look at them to make sure the wheels were working. The Maintenance Director had fixed the broken pipe after the fall. During an interview on 08/08/24 at 12:58 P.M., CNA 7 indicated the use of the shower bed was really based on the mobility needs of the resident. It took two staff members to get a resident on and off of the shower bed. You would have two staff members because you would be using a mechanical lift to transfer the resident onto the shower bed. If a resident was using a shower bed they would be using a mechanical lift too. Once the resident was on the shower bed you didn't need two staff members present to shower the resident if a staff member could roll the resident by themselves. Staff were trained on using the shower bed when they first started working at the facility, it was part of their orientation. When she used the shower bed, she looked to make sure the four pins were in place. You would have to remove two of the pins to lower the rail on one side to get the resident on the shower bed, and ensure the pins were back in place once the resident was on the bed. The rail would fall if both pins weren't in place. If one pin was in place the railing would stay up, but it would be super flimsy. She didn't really check the shower bed for cracks in the tubing or loose pieces before she used it. She did make sure the pins were in place. She was unaware of any problems with a shower bed prior to the incident that occurred with Resident B. During an interview on 08/08/2024 at 3:07 P.M., the Maintenance Director indicated he did, in fact, replace the pipes at the end of the shower bed observed on Wing 3 after Resident B fell out of it. A cap was off and it was nowhere to be found. There were two holes in one end of one of the pipes on the bed for the pins to be placed in, he didn't know if there was a good hole and a bad hole. He didn't know which hole was being used. He looked up the type of piping the bed was made of, but he used Schedule 40 PVC pipe on it instead. He replaced the pipes with heavier pipes he purchased from a local hardware store. He was unsure of how old the shower beds were, he couldn't find a purchase receipt or anything. In the last three months (May, June, and July) he had been using a Maintenance Checklist where he documented the rounds he did each month to check the rooms in the facility. At 6:07 P.M., the Maintenance Director indicated he checked the shower beds monthly. He checked to ensure the pins were present. He did not check the structure around the bed rails or around the pins for cracks. He only checked the bottom part of the frame for cracks and checked wheel function. During an interview on 08/09/2024 at 1:35 P.M., CNA 8 indicated staff should roll a resident towards themselves when using a shower bed. There was no situation in which they would roll them away from themselves when they were alone and giving a shower. The current facility policy titled, Accidents and Supervision with an implemented date of 9/1/22, indicated, .The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: Identifying hazard(s) and risk(s). Evaluating and analyzing hazard(s) and risk(s) .Monitoring for effectiveness and modifying interventions when necessary .The facility shall establish and utilize systemic approach to address resident risk and environmental hazards to minimize the likelihood of accident .All staff .are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident . The current JOB ORIENTATION-CERTIFIED NURSE AIDE with a revised date of 1/9/2008, was provided by the Administrator on 08/08/24 at 1:20 P.M. The orientation indicated, .assisting residents in/out tub/shower .Showering residents . CNA 2's training record indicated the CNA training curriculum .PROCEDURE #30: TRANSFER: TO STRETCHER/SHOWER BED, dated 04/27/21, .included but was not limited to, place stretcher/shower bed at bedside. NOTE: Make certain wheels are locks. After locking wheels, ensure bed and stretcher/shower bed are at the same height. Then lower side rails .Staff should be present at the bedside as well as on the opposite side of stretcher/shower bed. (Requires a minimum of two staff members .Center and align resident. Place pillow under his/her head and cover with a blanket and raise the rails of stretcher/shower bed . The current facility policy titled, Resident Showers with a revised date of 02/22/24, was provided by the Administrator on 08/08/24 at 1:20 P.M. The policy indicated, .It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice . The undated OPERATION INSTRUCTIONS for the shower bed was provided by the Administrator on 08/08/24 at 11:12 A.M. The record indicated, .UNLESS TRANSFERRING, WHEN THE PATIENT IS ON THE SHOWER BED, KEEP RAILS UP AT ALL TIMES .WHEN USING A LIFT TO TRANSFER THE PATIENT IN AND OUT OF THE SHOWER BED, MANUFACTURER RECOMMENDS KEEPING THE SIDERAILS UP AND LOCKED AT ALL TIMES .DO NOT ROLL USER AWAY FROM YOU UNLESS THERE IS A PARTNER CAREGIVER ON THE OTHER SIDE .SAFETY/MAINTENANCE INFORMATION .Check pipe and fittings for hairline fractures monthly .Check all junctures to make certain the pipe and fittings do not pull apart . The current, undated, manufacturer's PVC Healthcare Equipment catalog, indicated .[name of manufacturer] uses only top quality materials; a proprietary blend of PVC, strong and durable fittings specifically designed for healthcare and fabrics chosen for appearance and longevity .Surpasses all FDA [Food and Drug Administration] compliance standards . The Immediate Jeopardy, that began on 08/05/24, was removed on 08/10/24, when the facility conducted the following: The altered shower bed was taken out of service, the Maintenance Director received education to never alter medical equipment and to replace parts with the manufacturer's instructions, all residents who required the use of the shower bed were identified and the assignment sheet and care plan were updated, all staff were educated on the correct use, safety inspection, safety features of the bed and all safety measures to be taken related to the shower bed. This deficiency relates to Complaints IN00440484, IN00440575, and IN00440383. 3.1-45(a)(1) 3.1-45(a)(2)