Resident Left Unsupervised During Shower Despite Fall Risk
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision to a resident with a history of falls and paraplegia during showering. The resident, who was cognitively intact but dependent on staff for toileting, transfers, and showering, was observed being left alone in the shower room by a CNA for several minutes while the CNA left to retrieve bath sheets. During this time, the resident remained seated on a shower chair with the door closed and the call light out of reach. The resident confirmed in an interview that staff often left her alone in the shower room with the door closed to retrieve forgotten items, and that the call light was not accessible to her during these times. She expressed feeling scared and uncomfortable due to her history of falls and inability to call for assistance if needed. The resident's care plan identified her as a fall risk and included interventions such as ensuring the call light was within reach and anticipating her needs. Staff interviews revealed inconsistent understanding of the resident's supervision needs. One CNA stated that dependent residents should not be left unsupervised during showers and that all supplies should be gathered beforehand. Another CNA admitted to leaving the resident alone and not ensuring the call light was accessible, stating she was unaware the resident could not be left alone. The assistant director of nursing and the regional clinical resource initially provided conflicting statements regarding the resident's fall risk and supervision requirements, but later agreed that the resident should not have been left unsupervised.