Failure to Provide Adequate Supervision During Showering
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with diagnoses including dementia, chronic obstructive pulmonary disease, and emphysema. Clinical records and the Minimum Data Set (MDS) assessment indicated that the resident required supervision or touch-assistance for showering or bathing, and the care plan specified a need for setup assistance due to limited mobility. On the morning of July 5, 2025, a nurse aide set the resident up in the shower and instructed the resident to ring the call bell when finished. The aide checked on the resident after ten minutes, but then left the resident unsupervised for over an hour. When the aide returned, the resident was found to have fallen in the shower room. Facility leadership confirmed that adequate supervision was not provided during this time.