ATHENS, GA – PRUITTHEALTH – ATHENS HERITAGE

Based on observation, review of the facility Occurrences policy (effective date 7/1/2012 and reviewed 5/4/2016), record review, and staff interview, the facility failed to ensure that two staff persons were present during the provision of a shower for one resident (R) (R#4) of three residents reviewed for falls. This failure to ensure two persons were present during the provision of a shower resulted in R#4 rolling off the shower bed onto the floor and sustaining a laceration to her head that required five staples and a right foot fracture.

Review of the Nurse’s Note dated 9/29/2020 at 7:31 a.m. revealed that R#4 fell out of the shower chair during her shower resulting in a laceration to the back of her head. Pressure was applied to stop the bleeding, the Physician was notified, and the resident sent to the Emergency Department (ED). The resident’s Responsible Party was notified. Continued review of the resident’s medical record revealed that she returned to the facility the same day at 11:50 a.m. with five staples to the laceration on the back of her head and her right foot in a soft cast.

R#4 was assessed by the Nurse Practitioner on her return to the facility on [DATE]. Review of the Nurse Practitioner’s Progress Note dated 9/29/2020 at 12:28 p.m. revealed that the hospital CT scan showed a laceration to the resident’s scalp. An x-ray of her right foot showed a closed non-displaced fracture of the calcaneus (heel) bone. An x-ray of her pelvis was negative for fracture.

The facility failed to ensure that two staff persons provided R#4 her shower on 9/29/2020 resulting in the resident rolling off the shower bed and onto the floor and sustaining injuries to her head and right foot.