F0689

G

Failure to Maintain Safe Bed Positioning and Shower Supervision Resulting in Resident Head Injuries

Washington, District Of Columbia Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents, resulting in falls with head injuries. For the first resident, who had difficulty walking, muscle weakness, severe anemia, and fibromyalgia, the facility’s own Fall Prevention Program policy required that beds be locked and lowered so that the resident’s feet could be flat on the floor when sitting on the edge of the bed, and that high‑risk residents receive additional interventions such as a low bed. On the evening of readmission, nursing documentation shows the resident was received in bed, alert and verbally responsive. Shortly thereafter, staff were called to the room and found the resident on the floor between two beds, with the resident stating she had jumped out of bed trying to get to her chair. Assessment documented swelling and a superficial open area on the right forehead, and the resident was noted to be alert and oriented to 2–3, with confusion also documented on a fall risk evaluation.

Nursing notes further documented that the assigned nurse, upon receiving the resident around 11:03 p.m., checked the resident and noted that the bed was in a high position. The nurse attempted to lower the bed but was unable to do so and went to inform the supervisor about fixing the bed. Around 11:15 p.m., before the issue was resolved, the resident fell from the bed and was found lying on her face, bleeding, with swelling on the right forehead. Staff interviews corroborated that the bed was elevated and not in the lowest position, with the nurse supervisor stating that when she entered the room the bed was at maximum elevation and would not go down. The supervisor also stated that on readmission the nurse should complete a head‑to‑toe assessment and fall assessment and that the bed should be low with items in close proximity for safety, noting that the bed was elevated and things were out of place when she arrived.

For the second resident, who had muscle weakness, lack of coordination, left‑side hemiparesis, moderate cognitive impairment, and was dependent on staff for showers, the facility had identified the resident as a moderate fall risk. A nursing note documented that during shower time, the assigned CNA reported that while she and another staff member were assisting the resident by trying to turn him to the side, the resident sustained a fall in the shower room and was later noted with swelling on the right forehead. Subsequent documentation and interviews clarified that two CNAs were assisting the resident in the shower when the incident occurred. One CNA stated that the other CNA turned the resident toward him, but his hands were slippery with soap and he could not stop the resident from hitting his head on the wall, resulting in forehead swelling. The assisting CNA reported that he was on the side of the shower bed near the wall.

In a separate interview, the assigned CNA stated that she turned the resident toward the wall where she was standing in the shower room, and that the resident hit his head on the grab bar on the wall when he was trying to pull himself over. When asked why the resident was so close to the wall that he could hit his head, she stated that the resident required two‑person assistance for showers and that the room was too small for two people. She also stated that she did not tell the nurse that the resident fell. The unit manager later stated that both the nurse and the resident told her that he fell in the shower room while staff were giving him a shower, and she could not explain how the resident sustained a hematoma to the head while two staff members were assisting. These events demonstrate that the resident was positioned close enough to the wall and grab bar during assisted showering that he was able to strike his head, and that the assigned CNA did not initially report the fall to the nurse.