Failure to Provide Adequate Supervision and Safe Equipment During Shower Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including a history of falls, diabetes with polyneuropathy, and a left artificial hip joint, was not provided adequate assistance and safe equipment during a shower, resulting in a fall. The resident was assessed as high risk for falls and required partial to moderate assistance with bathing, meaning staff should provide less than half the effort but still assist with lifting, holding, or supporting as needed. During the incident, the resident was left unattended while the CNA retrieved a towel, and the shower chair's wheels were not locked, causing the chair to move on the sloped, wet floor. The resident reported that the shower chair wobbled due to the uneven floor and that the brakes were not engaged, which allowed the chair to move abruptly when the resident attempted to stand. The CNA was not within arm's reach at the time, and the resident fell forward, landing on the same hip previously fractured before admission. The resident experienced pain and bruising following the fall, and later required an X-ray to rule out a new fracture. The resident also described previous falls, including one at home and others in the facility, but specifically noted that this shower fall was due to equipment instability and lack of staff assistance at the critical moment. Observations and interviews with other staff and residents confirmed that the shower chair was unstable even when locked, and that not all CNAs consistently locked the wheels or provided direct assistance during transfers. The shower room's design, with a sloped floor and a lightweight, wheeled shower chair, contributed to the hazard. Staff acknowledged the potential for falls under these conditions and indicated that locking the chair and providing hands-on assistance were not always standard practice.