F0689

G

Failure to Supervise Resident During Shower Resulting in Fall and Multiple Fractures

Chicago, Illinois Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required supervision during a shower, resulting in a resident’s fall and injury. The resident was admitted with multiple medical conditions, including multiple pelvic fractures, chronic diastolic heart failure, diabetes mellitus, atrial fibrillation, muscle weakness, polyosteoarthritis, major depressive disorder, malignant neoplasm of the prostate, and the presence of a cardiac defibrillator. Assessment data showed the resident was cognitively intact and required partial/moderate assistance for showers, meaning staff were expected to provide less than half the effort but still lift, hold, or support the resident’s trunk or limbs as needed. The resident’s care plan and physician orders documented pain and mobility limitations related to a right hip fracture, non‑weight‑bearing or toe‑touch weight‑bearing restrictions, poor balance, and the need for staff assistance with dressing and mobility.

On the day of the incident, the resident reported that he was in the shower room attempting to take a shower and was unable to remove a tight sock. He stated that the CNA who accompanied him to the shower left the shower room, telling him she would be back, and that he then leaned over and fell to the floor. The resident stated that he normally received help in the shower and that staff usually stayed with him in case he needed assistance, including with removing his socks. He reported that when he fell, no one was in the shower room with him. Facility documentation from the RN’s progress note indicated that the resident was found lying on his right side on the shower floor, was able to answer questions, reported possible head impact, and complained of right lower extremity pain. A full body check and initial neuro checks were completed, and the resident was later found to have multiple fractures of the right hip and pelvis related to a mechanical fall in the shower from a standing position.

Staff interviews confirmed that the resident required significant assistance and supervision for showers and that he should not have been left alone in the shower room. The resident’s primary CNA stated that he required extensive assistance for showers, with two staff and a gait belt due to his restrictions, and that staff performed all of his care. The CNA involved in the incident stated she was accompanying the resident to the shower using his rollator when she saw another call light and left to answer it, instructing him to wait. She acknowledged that she normally set him up in the shower room, that he usually removed his footies while staff were present, and that she believed he would not have fallen if someone had been with him. The RN stated that the resident was not to be left unattended in the shower room and that he had not been informed the resident was going to the shower. The NP and DON both stated that a staff member should have been present in the shower room to supervise and assist the resident, and the DON clarified that residents who require supervision should not be left alone in the shower room and that staff are expected to have all needed supplies ready before entering so they can remain with the resident. The facility’s fall management policy stated that the facility will assess hazards and risks and implement appropriate interventions to minimize fall incidents and injuries, which was not followed when the resident was left unsupervised in the shower.

The hospital records documented that the resident sustained right acetabular/pubic rami fractures, a displaced fracture of the right iliac bone with fractures of the roof and medial aspect of the right acetabulum, a displaced fracture of the lateral right ischium, and displaced fractures of the right superior and inferior pubic rami as a result of the mechanical fall in the shower. Following the fall, therapy and nursing assessments described that the resident, who had previously been modified independent with a rollator for transfers and mobility, now required minimum contact guard assistance and use of a mechanical lift due to his new restrictions. The facility’s own fall log listed the resident as having had a fall on the date of the shower incident. These findings collectively show that the resident, who had known mobility limitations and required supervision and assistance for showering, was left unattended in the shower area, contrary to his assessed needs, staff expectations, and facility policy, leading directly to the fall and resulting injuries.