Failure to Ensure Safe Positioning and Supervision During Shower Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe shower environment and adequate supervision for a dependent resident, resulting in a fall from a shower chair and significant injury. The resident had multiple sclerosis, paraplegia, peripheral vascular disease, muscle wasting, gait and mobility abnormalities, and was dependent on staff for most care. She reported that during a shower, two CNAs were present and that from the start she felt she was not positioned properly in the shower chair, with her buttocks not fully in the seat opening. She stated she told staff this more than once, but they either did not hear her or ignored her. At the time of the fall, staff had her leaning forward so they could apply lotion to her back, and she described herself as leaning further forward than a normal sitting position. According to the resident, while she was leaning forward, she began to slip from the shower chair and ultimately fell, landing on her weaker right leg. She reported that one CNA commented she was slipping, but the resident still slid out of the chair and “went down hard enough” to break her leg. A CNA interview later confirmed that the resident slipped out of the shower chair while the CNA was leaning her forward to fasten her bra in the back. The CNA stated she did not hear the resident say anything during the shower. The nurse who responded to the shower room found the resident on the floor in a supine position with the shower chair to her left. At that time, the resident reported right knee soreness, rated 3/10, but no redness, bumps, bruising, or obvious deformity were documented. Subsequent documentation and interviews showed that the resident’s right knee became markedly swollen and that her usual right leg spasms were absent, as observed by a CNA on the overnight shift. The CNA reported the resident told her she had fallen from the shower chair and that she had not been fully seated in the chair. The CNA noted the leg was very swollen and questioned whether it might be broken. Imaging later revealed an impacted supracondylar fracture of the distal femur and a subacute proximal fibular diaphysis fracture. The facility’s fall investigation concluded the incident was unavoidable and described the resident as leaning forward to dry herself when she slid from the shower chair, with staff attempting to lower her to the floor. The resident’s care plan identified her as at risk for falls related to generalized weakness, immobility, MS, paraplegia, PVD, obesity, and osteoarthritis, and included an intervention for staff to ensure she was sitting centered and to assist with leaning forward, but this intervention was documented as created while the surveyor was in the facility investigating the fall.
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