F0689

D

Failure to Follow Care Plan and Bathing Restrictions for High-Risk Resident

Milton, Florida Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The facility failed to implement and maintain accident-prevention interventions for a resident with a known history of fall-related injury. After the resident sustained a right closed hip fracture and displaced hip from a fall from bed in late September 2025, the resident’s care plan was updated on October 2, 2025 to require a two-person assist for bed baths. A sticker system outside resident rooms indicated required assistance levels, and the sticker outside this resident’s room showed a two-person assist. A sign above the resident’s bed also stated “2-person assist, bed bath only,” and the resident’s daughter reported that this sign had been in place since the first injury. The resident’s daughters stated that the resident told them she was injured while being showered in January when staff pulled on her arm and hurt her.

Despite the care plan and posted signage specifying two-person assist bed baths only, documentation showed that the resident was taken to the shower on January 2, 2026, and that six additional showers had been documented since September 2025. A radiology report dated January 5, 2026, showed an acute left humeral neck fracture. A CNA reported assisting another CNA in bringing the resident to the shower in January, prior to the left arm injury. The MDS Coordinator stated that bath preferences should be listed on the care plan and acknowledged that the care plan had later been revised to indicate two-person assist for baths/showers, though she was unsure why this change occurred and stated there was no clinical contraindication to showers. The DON and Administrator confirmed they were aware that the family preferred two-person assist bed baths only and could not explain the care plan changes that allowed for baths/showers.