Patient's fall: patient should not have been left alone, mishandled.

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A thirty-seven year-old developmentally disabled woman lived in a six-bed adult foster care facility. She had been cared for by paid caregivers since the age of ten. It was difficult for her to ambulate independently and she wore braces on both legs to improve her stability.

On the day in question she had been given a hair permanent in the kitchen and was taken to the bathroom to rinse her hair.

Her caregiver left her standing alone in the bathroom without her leg braces only for a moment and she fell backward into the bathtub and broke her neck.

Then staff lifted her out of the bathtub without waiting for trained paramedics from the ambulance that was on its way.

The actual cause of death was never pinned down, that is, the fall or being handled incorrectly with a broken neck.

It was, however, not disputed she was not wearing her leg braces which normally stabilized her while she stood and she was momentarily left unattended.

Fall Care Plan Was Ambiguous

Her care plan did not expressly call for her not to stand up or...

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