Resident Left Unsupervised in Bathroom Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of falls, dementia with behavioral and mood disturbances, legal blindness, and impaired balance was left alone in the bathroom by a Certified Nurse Aide (CNA), despite care plans indicating the need for one-person assistance with toileting and transfers. The resident, who was known to be resistant to care and had severely impaired cognition, was observed by the CNA through a slightly open bathroom door. While attempting to put on underpants, the resident placed both legs in the same leg hole and, while trying to pull the sliding bathroom door, fell backwards, resulting in an abrasion and bleeding to the posterior scalp. Facility documentation and staff interviews confirmed that the resident required supervision and touching assistance for toileting due to high fall risk and cognitive impairment. The CNA reported that the resident refused care and insisted on privacy, leading the CNA to leave the resident alone but attempt to monitor them visually. There was no evidence of a care plan addressing the resident's resistance to care prior to the incident. The Director of Nursing stated that the resident should never be left alone in the bathroom due to their unsteady gait and high risk for falls, and that staff were aware of this requirement.