Failure to Provide Adequate Supervision During Shower Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent avoidable accidents, resulting in harm to a resident. The incident occurred when a nursing assistant was showering a resident with a history of falls, poor safety awareness, impulsive movements, and diagnoses including epilepsy, early onset dementia, altered mental status, and muscle weakness. While the resident was lying on a shower bed, the nursing assistant lowered the bed rail and turned away to place a blanket on a nearby chair. During this time, the resident sat up and slid off the shower bed, falling to the floor and striking her head. The fall resulted in a laceration and hematoma to the resident's head, requiring emergency room treatment and sutures. The resident's care plan included multiple interventions to prevent falls, such as bed in the lowest position, fall mats, hip protectors, and ensuring the environment was free of hazards. However, these interventions were not followed in the shower room, as the bed rail was lowered and the resident was left unsupervised, directly leading to the accident and injury.