Resident Left Unsupervised in Shower Resulting in Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis, a history of falls, and significant weakness was left unsupervised in the main shower room. The resident required total staff assistance for activities of daily living, including showers, and was identified as being at risk for falls. Despite these needs, the resident was left alone during a shower, which resulted in an unwitnessed fall and a fracture of the right femur. The incident took place when a certified nurse aide (CNA) assisting the resident became unable to understand the resident's needs, leading to the resident becoming upset and agitated. The CNA left the resident unattended in the shower room to seek help from another staff member, rather than using the call light and remaining with the resident. Upon returning, the CNA found the resident on the floor with the shower chair tipped over her. The resident sustained a right femur fracture, which required surgical intervention and hospitalization. Interviews with staff confirmed that the resident should not have been left unsupervised due to her dependence on staff for showers and transfers. The facility's fall management policy required that interventions be implemented based on assessed needs and communicated to direct care staff. Documentation and staff statements indicated that the resident's care plan called for maximum assistance and supervision during bathing activities, but these measures were not followed at the time of the incident.