Failure to Follow Fall Prevention Care Plan During Bathing
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions designed to prevent falls for a resident with dementia who was identified as a fall risk. The resident's care plan specified the need for supervision and touch assistance during bathing, use of a shower bench or bathtub, and wearing non-skid footwear when up. Despite these interventions, the resident was found unattended in the shower room by housekeeping staff, not fully clothed, without socks or shoes, and without a shower bench present. The resident was in a shower stall rather than a bathtub, and staff interviews confirmed that the care plan was not followed. As a result of these failures, the resident sustained multiple complex pelvic fractures and internal bleeding, requiring transfer to the hospital for evaluation. Staff statements and administrative confirmation indicated that the resident was left alone in the shower room, and the required safety equipment and supervision were not provided at the time of the incident.