Resident Left Unattended in Shower Room Due to Staff Communication Failure
Penalty
Summary
A deficiency occurred when a resident with significant medical complexities, including bilateral below-the-knee amputations, chronic heart failure, diabetes, chronic respiratory failure, and muscle weakness, was left unattended in the shower room for an extended period. The resident's care plan identified them as being at risk for falls and impaired skin integrity, requiring maximal assistance with bathing and toileting, and the use of a motorized wheelchair with orthotics/prosthetics. During a bathing session, the assigned CNA became ill and was sent home by the DON, who instructed the CNA to notify other staff about the resident. The CNA reported informing an LPN and another CNA, but the information was not effectively communicated, resulting in the resident being left alone in the shower room without a call light nearby. The resident reported being left in the shower room for approximately an hour, during which time they were seated in a shower chair and eventually had to pull themselves toward the door to seek assistance. Facility policy required staff to stay nearby during showers and check on residents every 5 to 10 minutes, but this protocol was not followed. Interviews with staff confirmed that residents should not be left unattended in shower chairs due to the risk of injury, yet the resident was left alone, and the incident was only discovered when a staff member found the resident after they had moved themselves to the door.