Failure to Provide Adequate Fall Prevention and Supervision During Bathing
Penalty
Summary
A deficiency occurred when the facility failed to develop and follow adequate fall prevention interventions for a resident assessed as high risk for falls. The resident had multiple diagnoses, including heart failure, diabetes, muscle weakness, abnormal gait, and required substantial or maximal assistance with bathing. The care plan specified that the resident should be supervised at all times while in the shower and that a towel should be placed on the shower chair to prevent slipping. Despite these interventions, an incident occurred when a CNA left the resident alone on the shower chair to retrieve a towel from the resident's room. During this time, the resident slid off the shower chair and was found on the bathroom floor. Documentation and interviews confirmed that the CNA did not follow the care plan's directive for continuous supervision during bathing. Other staff interviews indicated that it was standard practice to bring all necessary items into the bathroom before starting care and not to leave residents unattended during showers. The Director of Nursing stated that the resident should have received assistance as outlined in the care plan, but also indicated it was acceptable for the CNA to leave the resident briefly. There was no explanation provided for the discrepancy between the level of assistance required as indicated in the resident's assessment and the care plan. Facility policies required comprehensive, person-centered care plans and investigation of incidents to evaluate care and prevent recurrence, but these were not adequately followed in this case.