Failure to Secure Shower Room Door Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure that a shower room door was properly secured, resulting in a resident entering the room unsupervised and sustaining a fall that led to a fractured wrist. The resident involved had multiple diagnoses, including COPD, osteoporosis, delusional disorder, anxiety, and muscle weakness. She was assessed as having intact cognition but required partial to moderate assistance with most activities of daily living, including bathing and shower transfers. Her care plan noted a history of not waiting for assistance, self-transferring, and sometimes refusing staff help with ADLs. She was also identified as high risk for falls, with specific interventions outlined in her care plan, such as frequent staff checks and the use of non-slip materials. On the day of the incident, the resident requested a shower but was told by staff that assistance would be provided later. Despite this, she independently accessed the shower room, which was supposed to be locked but was left unsecured because the door was not fully closed. The resident entered the shower room, undressed, and attempted to shower without assistance. Staff discovered her on the floor of the shower room, having fallen and fractured her left wrist. The resident's wheelchair was found in the doorway, and her oxygen tank remained on her walker in her room across the hall. Interviews and documentation confirmed that the shower room door, although equipped with a keypad lock, was not pulled shut, allowing the resident to enter unassisted. The facility's policy required that accident hazards be minimized and that supervision and assistance be provided according to individual resident needs and environmental risks. The failure to ensure the shower room door was properly secured directly led to the resident's unsupervised access and subsequent injury.