Failure to Ensure Safe Environment Due to Dislodged Bathroom Track Door
Penalty
Summary
A deficiency occurred when a resident with multiple risk factors, including unspecified dementia, generalized muscle weakness, abnormal gait, cognitive communication deficit, and a need for assistance with personal care, was found on the floor outside their bathroom with the bathroom track door also on the floor. The resident had moderately impaired cognition and required partial to moderate assistance with toileting hygiene. On the day of the incident, staff heard a loud bang from the resident's room and found the resident in a left lateral position, asking for help to get up. The resident sustained a hematoma on the face and additional bruising, and subsequent X-rays revealed a left femoral neck fracture. The bathroom door was found next to the resident, but not on top of them, and the resident was unable to describe what happened. Interviews with staff, the maintenance director, and the resident's roommate indicated that there were no prior reports or documented issues with the bathroom track door before the incident. The maintenance director and several staff members stated they had not received any requests or notifications regarding problems with the door. The maintenance director noted that the door could potentially come off the track if bumped with enough force, but all safety mechanisms were reportedly intact at the time of the incident. The roommate did not witness the fall but heard the noise and believed the resident may have fallen against the door, causing it to come off the track. The facility had a system in place for staff to report maintenance issues, and both housekeeping and nursing staff were expected to report any concerns. However, no work orders or complaints about the bathroom track door were submitted prior to the event. The incident was unwitnessed, and the resident's cognitive impairment limited their ability to provide details. The deficiency centers on the failure to ensure a safe environment free from accident hazards, as the bathroom track door became dislodged during the resident's fall, contributing to the accident and resulting injuries.