F0689

G

Failure to Follow NWB Orders and Provide Safe Shower Conditions Leading to Fall

Bakersfield, California Survey Completed on 03-02-2026

Penalty

Fine: $56,265

Summary

The deficiency involves the facility’s failure to maintain a safe shower environment and to follow a resident’s non‑weight‑bearing (NWB) order to the right upper extremity (RUE), resulting in a fall with injury. The resident was admitted with diagnoses including a complete rotator cuff tear/rupture of the right shoulder, a rib fracture, generalized muscle weakness, abnormal gait and mobility, and a history of falling. The admission orders and therapy plan required a right arm sling to be worn at all times and specified NWB status on the RUE. The resident’s MDS showed she was cognitively intact, had functional limitation in upper extremity range of motion, was dependent for lower body dressing, and required partial/moderate assistance for sit‑to‑stand. The care plan and Kardex instructed staff to follow MD orders for weight‑bearing status and identified the resident as high fall risk.

On the date of the incident, the resident was taken to the shower room by a CNA who knew the resident wore a sling and had difficulty moving the right arm but did not know the resident’s weight‑bearing restrictions and did not ask nursing or therapy about them. The CNA instructed the resident to hold onto the grab bar with both hands while standing, despite the NWB order on the RUE. The CNA reported that the shower floor was “a little wet,” and that she typically turned on the water and waited for it to warm while undressing residents, which could leave water dripping onto the floor. The DON later confirmed the shower floor was wet from a prior shower. The resident was standing, barefoot, on this wet floor while the CNA partially removed her pants; the resident’s pants became tangled around her legs as she tried to remove them while standing.

According to the resident, the CNA stepped away while she was still standing with her pajama bottoms being removed, and the resident slipped on the wet, slippery floor and fell, striking the back of her head on the wall and her left arm on the floor tile. The nurse who responded found the resident on the floor with no shirt, pants and briefs partly off, bare feet, a bump on the back of the head, two skin tears on the left forearm with bruising, and limited ROM of the RUE. The resident reported pain to the head and left forearm and was crying. Emergency department records documented a mechanical fall in the shower while being held by a new CNA, with complaints of left knee pain, a skin tear to the left forearm, and a right humeral head fracture. Social services documented that after the fall the resident felt nervous and fearful about showers, therapy, and ADLs and did not want to fall again. The facility’s falls management policy required evaluation of fall risk and implementation of interventions to promote resident safety, but the resident was left standing on a wet shower floor, barefoot, with clothing around her legs and instructed to use both hands on the grab bar despite an RUE NWB order, leading to the fall and injuries described.

The facility also failed to ensure the resident was seated in the shower chair while being undressed. The CNA and DON both stated the resident was standing when her pants were being removed, and the CNA acknowledged the resident was trying to get her pants off one ankle while standing when she fell. The IDT post‑event analysis documented that the resident was in bare feet at the time of the fall and that she slipped on water and tangled her foot in her pant legs while trying to take them off, losing her footing and falling. A family member who was called into the shower room observed the resident lying on a wet floor, sobbing, with pants down below the knees, bare feet, and wet lower extremities. These observations confirm that the resident was not seated during undressing and was exposed to a wet, slippery surface while partially clothed and unsupported.

Therapy documentation on the day of the incident reiterated the NWB order on the RUE, and the PTA stated the resident could only use the left arm to hold the grab bar in the shower and that going against the NWB restriction could delay healing or worsen the fracture. The PTA and CNA both stated that CNA 1 should have asked nursing or therapy about the resident’s weight‑bearing restrictions before taking her to the shower. The DON acknowledged that the resident was NWB on the RUE at the time of the fall and that the resident was asked to briefly stand so her pants could be partially removed. Collectively, the record review and interviews show that the facility did not follow the resident’s NWB order, did not ensure she was seated while being undressed, and did not ensure the shower floor was dry and non‑slippery, resulting in the resident slipping and falling on the wet shower floor, sustaining head and left forearm injuries, pain, and subsequent nervousness about showers.