Resident Fall Due to Unattended Shower and Use of Broken Equipment
Penalty
Summary
A resident with diagnoses including diabetes, epilepsy, and bilateral above-knee amputations, who was cognitively intact and required substantial assistance for transfers, experienced a fall while in the shower. The resident's care plan specified that staff assistance was required at all times during showers, with a staff member to remain in the shower room throughout. On the day of the incident, a CNA placed the resident in a shower chair and left the resident alone in the shower to retrieve towels. During this time, the shower chair, which had previously been identified as broken and moved to the spa room to prevent use, failed and the resident fell onto the floor, hitting their back and head against the wall. Interviews and documentation confirmed that the CNA used the broken shower chair despite its known condition and left the resident unattended, contrary to the care plan and facility expectations. The incident was unwitnessed, but staff responded promptly after the fall. The resident was assessed and found to have no injuries, and neurological checks were performed. The event was reported by a housekeeper who observed the CNA leaving the resident alone and notified nursing staff.