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F0689
D

Resident Left Unsupervised During Shower

Kerrville, Texas Survey Completed on 05-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with diagnoses including asthma, COPD, lack of coordination, muscle weakness, and unsteadiness on feet, who required partial assistance for showering, was left unsupervised in the shower by a CNA. The resident reported being assisted into the shower and then left alone, after which he used the call light for help but did not receive a response. The resident experienced difficulty breathing due to the heat and humidity and, after waiting approximately 20 minutes, independently ambulated to his wheelchair and exited the restroom without assistance. Interviews confirmed that the CNA left the resident unsupervised to assist another resident or obtain supplies, despite facility policy requiring supervision during showers. The resident reported the incident to an LVN, who confirmed the resident's account. The CNA acknowledged leaving residents unsupervised at times and recognized the potential for harm, such as slipping. The DON confirmed awareness of the incident and facility policy against leaving residents unsupervised during bathing.

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