Resident Left Unattended in Shower Resulting in Fall With Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and interventions to prevent a fall for one resident identified as being at risk for falls. The resident had multiple diagnoses, including type 2 diabetes mellitus, osteomyelitis of the right ankle and foot, cervical spinal stenosis, major depressive disorder, bipolar disorder, left below-knee amputation, and morbid obesity. The resident’s BIMS score was 15, indicating intact cognition, and the care plan identified the resident as high risk for falls due to deconditioning, with interventions such as prompt response to requests for assistance, ensuring the call light was within reach, following the facility fall protocol, and ensuring non-skid footwear when ambulating or mobilizing in a wheelchair. A Morse Fall Scale score of 40 indicated a moderate fall risk. On the date of the incident, documentation initially described the event as an unwitnessed fall in the shower room, with the resident reportedly stating she slipped off from her bed, and an x-ray was ordered for left hip pain. A subsequent nursing note documented that the x-ray showed an acute fracture of the left hip at the intertrochanteric region, and the resident was sent to the ED. A later incident note clarified that the resident had sustained a fall inside the shower room after being left alone by a CNA, despite report that the resident required a two-person assist for transfers and use of a Hoyer lift. The CNA left the resident alone twice to get assistance to stand the resident, and the resident was found on the floor complaining of left hip pain. Interviews with staff confirmed that residents should never be left unattended in the shower. The DON stated that residents should not be left alone in the shower and acknowledged that the resident was left alone, even if only for a brief period, and that the resident was typically able to ambulate with little assistance but was feeling weak that day. A CNA with over twenty years of experience stated that shower procedures include positioning the wheelchair and shower chair for stability and that, while ideally two staff assist, it can be done with one; she also stated it was never permissible to leave a resident unattended in the shower. An LPN reported assisting the CNA with pulling up the resident’s pants and brief and helping get the resident back on the shower chair; after being told by the CNA that she could leave, the LPN departed and later learned the resident had been left unattended. The facility’s shower policy required assisting residents with bathing, helping them into the shower, ensuring the shower chair is locked if the resident remains seated, and encouraging use of safety rails, but the resident was left alone in the shower room contrary to these expectations and the resident’s assessed need for assistance.
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