F0689

G

Unsupervised Common-Area Bathroom Use Leads to Unwitnessed Fall With Head Laceration

Grand Blanc, Michigan Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a cognitively impaired resident who fell in a common-area bathroom. The resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5/15, dementia, Alzheimer’s disease, repeated falls, and a history of an intracapsular right femur fracture from a prior unwitnessed fall that required surgical repair. The resident’s MDS Section GG and MD orders showed she required at least one-person assistance for transfers and two-person assistance with a walker, and needed substantial to maximal assistance with toileting, hygiene, and lower-body dressing. She was also incontinent and on Plavix, a blood thinner that may cause bleeding. Despite these documented needs and risks, the care plan did not include specific interventions for assisting her to and from the bathroom, and the incontinence care plan intervention to provide assistive devices had not been updated or revised since its original date.

On the date of the incident, the resident was seated with other residents in a common area after lunch, near the common-area bathroom by the dining room. At approximately 1:05 PM, she went alone into the common-area bathroom without staff assistance. No staff were present in the common area at that time, and there was no call light access in the common area when residents needed to use the bathroom. A CNA walking by heard the resident screaming for help and found her on the bathroom floor; the fall was unwitnessed. The CNA notified the RN, who responded and found the resident lying face down next to her wheelchair, with blood all over the floor and a laceration on the top of her head and a hematoma on the left side of her forehead. The fall incident report documented that the resident stated she had been using the bathroom and attempted to get back into her wheelchair when she fell.

Interviews and record review confirmed that no staff had taken the resident to the common-area bathroom or were monitoring the residents in the common area at the time of the fall, despite the resident’s known impulsivity, tendency to forget she needed assistance, and care plan direction that she needed to be watched and not left without staff in the common area. The RN who responded to the fall confirmed that no staff were in the common area when the resident was found, only a group of residents. The social worker who completed the BIMS assessment reported that the resident was more confused in the afternoon, required one-person assistance for transfers, and should not have gone to the bathroom on her own. During interviews, the DON and Administrator asserted that residents have the right to go to the bathroom on their own and cannot be stopped, and the Administrator initially believed the fall had occurred in the resident’s own bathroom rather than the common-area bathroom. The facility’s Fall Reduction Program, which is intended to provide a safe environment and reduce risk, was in place but the implementation for this resident did not prevent her from being left unsupervised in the common area and accessing the bathroom alone, leading to an unwitnessed fall with a head laceration requiring six staples and a hematoma.

On a subsequent observation, the resident was seen in the hallway, confused, teary-eyed, and self-ambulating in her wheelchair, unable to state her name or room number, with visible bruising on both sides of her head and a healing scalp laceration. A staff member was yelling her room number from down the hall rather than directly assisting her, and the DON ultimately led her into her room and shut the door. This observation further illustrated her ongoing confusion and need for direct assistance and supervision, consistent with the prior assessments and fall history documented in her record.