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).