Failure to Provide Required Supervision During Shower Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who required supervision or assistance with showering and transfers due to abnormal gait, mobility issues, and a history of falls, was left unsupervised during a shower. The resident's care plan documented the need for assistance with activities of daily living and identified a risk for falls. Despite these documented needs, the resident was alone in the shower when he attempted to sit down after standing to wash his hair, resulting in a fall. The resident reported that no one was present to assist him, and staff interviews confirmed inconsistent supervision practices during showers, with some staff stating they would stay with the resident and others indicating supervision varied by shift. The fall resulted in the resident sustaining redness to his knees and forehead, as well as complaints of lower back pain. The resident was assessed and subsequently transported to the hospital for evaluation, where imaging studies were negative. The facility's fall policy emphasized the identification and evaluation of residents at risk for falls and the implementation of preventive strategies, but in this instance, the required supervision was not provided, directly leading to the resident's fall.