Resident Left Unattended in Bathroom Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's Disease, stroke with right-sided hemiplegia and hemiparesis, and vascular dementia was left unsupervised in the bathroom. The resident was severely cognitively impaired and required maximal assistance with toileting hygiene, personal hygiene, and toilet transfers, as documented in the Minimum Data Set assessment. The resident's care plan specifically identified falls as a concern and included interventions such as not leaving the resident alone and gathering all necessary items before providing care. Despite these interventions, a nurse aide left the resident alone on the toilet to retrieve an incontinent brief from the hallway. During this time, the resident stood up without assistance, fell forward, and sustained injuries including an abrasion and large bump to the forehead and an abrasion to the left knee. The incident was confirmed through clinical record review, staff interviews, and direct observation of the resident's injuries. The facility's policy required staff to implement interventions tailored to the resident's fall risk, which was not followed in this instance.