Failure to Provide Supervision During Resident Showers
Penalty
Summary
The facility failed to provide adequate supervision during showers for two residents, both of whom required assistance or supervision due to their medical conditions. One resident, with a history of chronic kidney disease, hemiplegia, and a high fall risk, was observed sitting alone in a shower chair, covered in soap and water, without staff present and without a call light within reach. The resident reported being unable to transfer independently and stated that staff routinely left him unattended in the shower, despite his preference for staff to remain in the room for safety. Staff interviews confirmed that the resident was left alone, with the assigned CNA stating it was routine to leave him unsupervised, and the LPN and DON both acknowledging that supervision was required but not provided. Another resident, diagnosed with moderate intellectual disabilities, diabetes, and atrial fibrillation, was also observed alone in a shower chair, unsupervised, with water running and soap suds present. The DON verified that this resident should not have been left unattended, and both the assigned CNAs confirmed that the resident was left alone in the shower room. The resident reported being left alone for several minutes on multiple occasions and expressed fear of fainting or falling while unsupervised. The DON stated that supervision during showers meant staff should remain in the room at all times, and the Administrator was unaware that residents were being left unattended during showers. The facility did not provide a policy regarding supervision during showers when requested. The lack of supervision for these residents, both of whom required assistance or supervision due to cognitive or physical impairments, constituted a failure to ensure a safe environment and adequate supervision to prevent accidents, as observed and confirmed by staff and resident interviews.