Resident Left Unattended in Bathroom Resulting in Fall and Injuries
Penalty
Summary
A resident with moderate cognitive impairment, non-Alzheimer's dementia, Parkinson's disease, anxiety disorder, and depression was identified as high risk for falls and required substantial to maximal assistance with transfers and toilet use. The resident's care plan specifically included an intervention to not leave the resident unattended in the bathroom due to impaired balance, poor safety awareness, and a history of falls. Despite these documented needs and interventions, the resident was left alone on the toilet in the bathroom by a Training Nurse Assistant (TNA), who then left the area to retrieve a brief and subsequently went on a meal break without notifying other staff that the resident was unattended. The incident occurred when the TNA, after placing the resident on the toilet, left to find a larger brief and was then called to dinner by an LPN. The TNA, feeling intimidated and distracted, went to dinner and forgot to inform anyone that the resident remained in the bathroom. During this time, no other staff were aware of the resident's location or that he was left unattended. The resident attempted to get up unassisted, resulting in a fall that caused multiple injuries, including abrasions and skin tears to the elbow, hip, buttock, and hand, as well as visible bleeding and bruising. Staff interviews confirmed that the resident was not to be left alone on the toilet and that this information was available in the care plan, Kardex, and communication book. The facility had a system in place to highlight residents who should not be left unattended, and staff were expected to be knowledgeable about each resident's care needs. Despite these protocols, the failure to follow the care plan and provide adequate supervision directly led to the resident's fall and subsequent injuries.