Resident Left Unattended on Toilet During Vomiting Leads to Unwitnessed Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent accident hazards for a resident who experienced a change in condition while on the toilet. A resident with diagnoses including chronic kidney disease, hypertension, anemia, asthma, and a left great toe amputation was admitted with a moderate fall risk and care plan indicating the need for assistance or supervision with mobility, transfers, ambulation, and toileting. Functional assessments documented that the resident required partial to moderate assistance with toileting and transferring, and nursing notes indicated the resident needed 1–2 person assistance with transfers. The resident had recently tested positive for C. difficile, was receiving antibiotics and IV fluids, and had been experiencing diarrhea. On the day of the incident, the resident was assisted to the toilet by a CNA and began vomiting, which was a new symptom according to the ADON. Despite this change in condition, the CNA left the resident alone on the toilet to get the nurse, rather than remaining with the resident and using the call light or calling out for help, as later described by interviewed staff as the expected practice when a resident vomits on the toilet. When the nurse and CNA returned, they found the resident face down on the bathroom floor with a laceration on the right side of the head and vomit present on the floor. The fall was unwitnessed, and the resident reported having passed out and not remembering what happened. Facility documentation, including fall event and investigation reports and an interdisciplinary note, confirmed that the resident had been left unattended on the toilet during vomiting and was later found on the floor with a head injury. Hospital emergency department records indicated the fall was due to hypovolemia and a vasovagal response. The facility’s fall management policy identified all new admissions as fall risks, but staff practice allowed residents to be left alone on the toilet when staff felt they were safe, contributing to the circumstances of this incident.
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