Mentally Disabled Patient Drowns in Nursing Home Shower

This case involves a patient with significant mental disabilities. She was living under the full-time care of an assisted living facility. The patient’s care plan specifically stated that she must be observed while bathing and during numerous other activities of daily living. However, during this incident, she showered with no supervision and had a seizure while bathing. The patient was found dead in the bathroom and the cause of death was attributed to drowning. Furthermore, this patient was non-verbal and couldn’t call for help if she required assistance upon falling while bathing. It was noted that the facility had never requested a revision to the patient’s supervision protocol; however, since she had bathed without the need for much assistance, the staff regularly allowed her to bathe on her own (unbeknownst to the facility managers).

Question(s) For Expert Witness

1. What is your experience with situations such as the one mentioned above and should the patient have been monitored more closely?

Expert Witness Response E-004523

I have considerable experience working at long term care facilities, specifically those caring for mentally disabled patients. In all circumstances, the staff must follow the instructions for supervision prescribed for a senior living resident. It is certainly a breach in the standard of care to have allowed the woman to bathe on her own, given her declining ability to handle activities of daily living on her own. The staff would be required to request a revision to the patients orders by a licensed physician - they are not allowed to simply make up rules as they see fit.