Resident Left Unattended in Shower Chair Resulting in Fall and Head Laceration
Penalty
Summary
The facility failed to protect a resident from neglect by not providing adequate supervision during a transfer, resulting in a fall with injury. The resident had been admitted with diagnoses including cerebral infarction, encephalopathy, and a urinary tract infection, and had physician orders requiring the assistance of two staff members for transfers. The resident’s care plan identified a moderate risk for falls related to deconditioning and gait/balance problems. On the day of the incident, a nurse aide (Employee E1) assisted the resident with a shower, placed the resident in a shower chair, completed the shower, and returned the resident to the room in the shower chair. According to the nurse progress note and investigative documents, Employee E1 left the resident unattended in the shower chair in the room while going to obtain a Hoyer lift for transfer back to bed. During this time, the resident fell from the shower chair and sustained a head laceration that required transfer to the hospital. Witness statements from nursing staff documented that Employee E1 acknowledged he did not ask anyone to stay with the resident, that no one was with the resident while he went to get the lift, and that he knew residents should not be left unattended in a shower chair. Other nurse aides interviewed stated they knew not to leave a resident alone in a shower chair and would refer to the kardex or nurse for care instructions. The DON confirmed that the facility neglected to provide proper supervision for the resident, resulting in a fall with injury.
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