Unsafe Dining Room Flooring Creates Fall Hazard
Penalty
Summary
A deficiency was identified when the facility failed to maintain a safe walking environment for a resident at risk for falls. Observations revealed that the dining room floor had two visible seams running its length, with areas where the laminate flooring was puckering and lifting from the surface, creating a tripping hazard. Additionally, a brown, sticky substance, identified as floor glue mixed with debris, and tiny nails were present along the seams. Residents and staff reported that the floor had been in this condition for at least a month, and complaints had been made about the hazard, but the flooring had not been replaced or adequately repaired. One resident, who was cognitively intact, reported witnessing another resident fall due to the floor condition and expressed concern about the risk posed by the puckered flooring and sticky substance. Another resident, who had moderate cognitive impairment and multiple diagnoses including dementia, anxiety, diabetes, and reduced mobility, described a fall in the dining room where his foot got stuck on the sticky floor, causing him to trip and fall face-first, resulting in a bloody nose and bruising. This resident required hospital evaluation but did not sustain fractures. The resident's care plan had previously identified him as a fall risk, and after the incident, interventions included maintaining a safe environment. Interviews with facility staff, including the Maintenance Director, DON, and RN, confirmed ongoing issues with the dining room floor seams, with staff acknowledging that residents' walkers and wheelchairs sometimes got caught on the seams. The Maintenance Director stated that attempts had been made to repair the floor with glue and nails, but the problem persisted. The Administrator acknowledged awareness of the hazard and agreed that the condition of the floor could pose a problem for resident safety. Facility policy required malfunctioning equipment or hazards to be immediately addressed, but the unsafe floor condition remained unresolved at the time of the survey.