Resident Left Unattended in Shower Chair Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was assessed as dependent for all activities of daily living (ADLs) and had poor sitting balance, was left unattended in a shower chair by a certified nurse assistant (CNA). The resident's care plan and mobility assessment documented significant cognitive and physical impairments, including severe cognitive deficits, poor trunk control, and inability to maintain sitting or standing balance. Despite these documented needs, the CNA turned her back on the resident while the resident was in the shower chair, leaving the resident unsupervised. As a result of being left unattended, the resident fell from the shower chair in the shower room, sustaining a laceration to the forehead and an acute nondisplaced fracture of the first cervical vertebra (C1). The resident was transported to a general acute care hospital, where additional injuries, including a forehead hematoma and blunt head trauma, were diagnosed. Interviews with facility staff confirmed that the resident required total assistance during showers and that the facility's shower chair could not be reclined, which may have contributed to the resident's inability to maintain balance. Further review of facility policies indicated that staff were required to stay with residents throughout bathing and never leave them unattended in the tub or shower. Staff interviews and documentation confirmed that the resident was not using a reclining wheelchair or shower chair prior to the incident, despite recommendations that such equipment could have helped prevent falls for residents with poor balance and trunk control. The failure to provide adequate supervision and appropriate equipment directly led to the resident's fall and subsequent injuries.