Failure to Provide Adequate Supervision During Bathing Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of cerebrovascular disease, muscle weakness, and moderate cognitive impairment was left unsupported on a shower bench during bathing. The resident, who required substantial to maximal assistance for activities of daily living and was at high risk for falls, was left unattended by a CNA who turned away to retrieve a towel. The resident subsequently fell from the shower seat, hitting their head and sustaining an injury that required hospitalization. Facility documentation, including the resident's care plan and Kardex, did not specify the level of staff assistance required for bathing, despite the resident's known physical limitations and high fall risk. Interviews with staff revealed uncertainty and lack of clarity regarding the number of staff needed to safely assist the resident during bathing. The CNA involved was unaware of the specific assistance requirements, and the Kardex section for bathing assistance was left blank, leaving staff without clear guidance. The facility's investigation into the incident was limited to collecting witness statements and did not include a review of the resident's need for support while sitting or an analysis of the circumstances that led to the fall. There was no evidence that the facility identified the risk created by leaving the resident unsupported or that staff were adequately informed of the resident's care needs during bathing. As a result, the resident experienced a preventable fall and injury.