Failure to Address Environmental Hazards Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to comprehensively assess and address environmental hazards, specifically regarding the storage of mechanical lifts in resident hallways. A resident with dementia, muscle weakness, unsteady gait, impaired safety awareness, and a history of falls was identified as high risk for falls. Despite these risk factors, the resident was able to ambulate independently with a walker and required limited assistance for activities of daily living. On the date of the incident, the resident tripped over a mechanical lift that was parked against the wall just outside her room, resulting in a fall that caused multiple rib fractures, hemothorax, an unstable T11 spinal fracture, and a large laceration to her elbow. Interviews with staff and family members confirmed that the mechanical lift was parked one to two feet from the resident's doorway, and the resident's walker became entangled with the lift, leading to the fall. Multiple staff members, including nursing assistants and LPNs, reported inconsistent and unclear guidance regarding where to park mechanical lifts. Training focused on using the lifts but did not address environmental safety hazards or designate specific storage locations. Staff relied on personal judgment to park lifts in the hallway, and several did not recognize the lifts as potential tripping hazards. Observations during the survey revealed that mechanical lifts were routinely parked in hallways near resident doorways, with no designated storage areas. The facility's environmental hazards policy required maintaining a safe and orderly environment, but there was no evidence of recent staff education or audits related to environmental safety or the safe storage of mechanical lifts. The interdisciplinary team and facility leadership did not consider the placement of the lift as a contributing factor to the resident's injuries during their review of the incident.