Resident Fall Due to Inadequate Supervision in Bathroom
Penalty
Summary
A deficiency occurred when a resident with a recent history of traumatic subdural hemorrhage, muscle weakness, and impaired safety awareness was left unattended in the bathroom. The resident had been admitted to the facility only a few hours prior, with documented left-sided weakness, slurred speech, and cognitive impairment. Despite being identified as a moderate fall risk with deconditioning and gait/balance problems, the resident was transferred to the toilet by a CNA, who then left the resident alone in the bathroom at the resident's request for privacy. The CNA was away for approximately two minutes, during which time the resident fell and sustained a scalp laceration requiring emergency medical attention and laceration repair with staples. Interviews and record reviews confirmed that staff were aware of the resident's fall risk and cognitive limitations. The facility's policy and the Director of Staff Development indicated that staff should remain close to residents identified as fall risks, even if privacy is requested, and should stay within reach or just outside the bathroom door. However, this protocol was not followed, resulting in the resident being left unsupervised and subsequently experiencing a fall with injury.