Failure to Provide Adequate Supervision During Shower Resulting in Resident Fall and Injury
Penalty
Summary
A dependent resident with a history of sacral fracture, aortic aneurysm, and lumbar radiculopathy, who was prescribed daily anticoagulant therapy, was involved in an incident during a shower. The resident required moderate to maximum assistance for bathing and transfers, and her care plan identified her as being at risk for falls and abnormal bleeding due to medication use. While being assisted by a nursing assistant (NA) on a shower bench without sides or railings, the resident suddenly became unresponsive and went limp. The NA responded by laying the resident across the shower bench, turning off the water, and leaving her side to seek help by running approximately 10 feet to the door to yell for assistance. During this time, the resident was left unsupported on the bench and subsequently slid off, falling to the floor and sustaining a laceration to her right eyebrow with significant bleeding, bruising, and a skin tear to her right elbow. The NA later acknowledged that an emergency call bell was present in the shower stall but did not use it, as it was behind her and she did not think to utilize it in the moment. Interviews with facility staff, including the Medical Director and Director of Nursing, confirmed that staff are expected to ensure residents are in a safe position before leaving them unattended. Observations of the shower room confirmed the lack of safety features on the bench and the location of the emergency call bell. The incident report and staff interviews corroborated that the resident was left unsupported, leading to the fall and resulting injuries.