Failure to Provide Adequate Supervision During Shower Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of paraplegia, multiple sclerosis, morbid obesity, and cognitive communication deficit, who required substantial to maximal assistance with bathing and transfers, was left unsupervised during a shower. The resident was known to be at high risk for falls, required a mechanical lift with two-person assistance for transfers, and had a care plan indicating the need for extensive staff assistance during bathing. Despite these documented needs, the resident was left alone in the shower room after requesting privacy, with the CNA stepping outside the room but remaining within arm's reach. During the unsupervised period, the resident dropped a towel and attempted to retrieve it, resulting in a fall from the shower chair. The incident was not witnessed, but staff responded to the resident's calls for help and found her on the floor in pain. The resident sustained a closed fracture of the left femur, requiring hospitalization and orthopedic evaluation. The call light was not activated at the time of the fall, and the resident reported that she thought she could reach the towel herself but lost access to the call light in the process. Interviews with staff revealed that the facility's policy required staff to remain with residents throughout bathing and never leave them unattended in the shower or tub. Staff members acknowledged the resident's need for assistance and the policy requirements, but the CNA involved believed she was honoring the resident's request for privacy. The Director of Nursing confirmed that, despite the resident's preference for privacy, staff should not have left her unattended due to her care needs and facility policy.