Resident Fall Due to Inadequate Supervision and Failure to Follow Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident with a history of artificial hip replacement, difficulty walking, and osteoarthritis of the hip, who was identified as being at risk for falls due to unsteady gait, balance issues, and decreased strength, sustained a fall during a shower. The resident's care plan required partial to moderate assistance for showers, dressing, and transfers, and included interventions such as keeping personal items within easy reach and providing safety instructions. However, during the shower, a Certified Nursing Assistant (CNA) placed the resident's personal items on top of a heater, out of the resident's immediate reach. While the CNA was assisting with drying and turned away to retrieve the resident's wheelchair, the resident attempted to access her personal items, causing the shower chair to move and resulting in a fall. The resident suffered a skin tear, reported hitting her head and hurting her back, and was subsequently sent to the hospital for evaluation. Staff interviews confirmed that the CNA recognized the error in not keeping personal items within the resident's reach and acknowledged that the shower chair could move, especially given the resident's height and positioning. Another nurse stated that the shower chair can move depending on the resident's position and emphasized the importance of not leaving or turning away from a resident in the shower room. The facility's Fall Prevention and Management Program policy required staff to follow care plan interventions, including keeping personal items within reach, to minimize fall risk. These actions and inactions led to the resident's fall and injury during the shower.