Failure to Use Blind Spot Mirror Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to utilize a blind spot mirror before opening a set of double doors, resulting in a fall for a resident. The resident, who was admitted for skilled nursing and rehabilitation, was observed ambulating with a four-wheeled walker in the memory care unit. According to the fall investigation report, the resident was walking near the front door when a dietary aide opened the door, which struck the resident and caused her to lose balance and fall. A certified nursing assistant witnessed the incident and confirmed that the aide did not see the resident due to a blind spot. Interviews with staff revealed that a blind spot mirror was installed on the wall to allow visibility of the other side of the door before opening it. The dietary aide involved in the incident acknowledged that she should have checked the mirror prior to opening the door. The administrator confirmed that staff are expected to use the mirror to prevent such accidents, but in this instance, the procedure was not followed, directly leading to the resident's fall.