A resident needing assistance to get in and out of the tub was permitted to bathe privately in the whirlpool located in facility’s spa room. The resident drowned in the tub. State inspectors found the facility in violation of federal and state regulations because there was no resident-accessible call system installed in the spa room. Failure to provide a Resident Call System (F919) and failure to keep the resident free of Accident Hazards/Supervision/Devices (F689) constitutes substandard quality of care and may lead to submission of false claims.
Compliance Perspective – Call System:
The Compliance and Ethics Officer with the Administrator, Director of Maintenance and the DON will review the facility’s alarm/call system to ensure that it meets federal and state requirements concerning placement and accessibility for residents needing to call staff for assistance. Staff will be educated and trained about performing and keeping up-to-date safety/risk assessments on residents that seek to independently participate in activities such as private bathing. The DON will oversee periodic audits of all the residents’ safety/risk assessments to determine if there are residents whose assessment should preclude them from performing independent activities like private bathing.
Last March, a resident in a Missouri nursing home was found dead in the spa room where she had been using the whirlpool tub. The spa room did not have an accessible call system installed for residents to use in case of an emergency. Staff at the nursing home told investigators that the resident often requested that she be allowed to bathe in private and that she enjoyed taking long baths. It was also noted that while the resident enjoyed and often bathed independently, she needed assistance getting in and out of the whirlpool tub.
One of the facility’s CNAs told the inspectors that staff checked on the resident every 5-10 minutes whenever she bathed because there was no other way for the resident to request help if she needed it.
The police confirmed to news media initially that they were investigating the death but later reported the resident’s death as accidental.
State inspectors from the Missouri Department of Health and Senior Services (DOHSS) investigated the incident and determined that the nursing home was in violation of state and federal regulations requiring nursing facilities to “be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area.” Such call systems are to be at residents’ bedsides and at all “toilet and bathing facilities.”
The facility “agreed to install an audio and visual alarm system for the spa room.” Staff would also perform safety risk assessments for residents desiring to bathe independently and maintain a list of residents who were cleared to do so.
Although the DOHSS has responded to four complaints about the nursing home in the past year, last month an inspection of the nursing home found no violations of state requirements.
