Failure to Prevent Accidents Due to Unsafe Environment and Equipment
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision to prevent accidents for two residents with dementia and high fall risk. In the first instance, a resident with moderately impaired cognition, a history of wandering, and high risk for falls and elopement was left unsupervised when a normally secured bathroom door was left ajar and unlatched. The resident accessed the bathroom independently, resulting in an unwitnessed fall that caused a large hematoma, rib fracture with a partially collapsed lung, and two brain bleeds, requiring emergency hospitalization and trauma surgery. Staff interviews revealed that the bathroom door had a malfunctioning keypad lock and was routinely left open due to difficulty in operation, and maintenance requests for repair were either not submitted or not acted upon in a timely manner. In the second instance, another resident with severe cognitive impairment, hemiplegia, and multiple comorbidities experienced a fall during an assisted shower. The fall occurred when the wheel of a small, white shower chair became stuck on a floor drain, causing the chair to tip and the resident to fall, resulting in a hip fracture that required surgical repair. Staff and maintenance interviews confirmed that the shower chair was old, had worn and malfunctioning wheels, and was known among staff to be unsafe. Despite this, the chair remained in use, and only partial repairs were made after the incident. The resident continued to experience severe pain for weeks following the fall, and diagnostic imaging confirming the fracture was delayed. Both incidents demonstrate a failure to identify and address environmental hazards and to ensure that equipment used for resident care was maintained in safe, operable condition. The facility's own policies required the environment to be free from hazards and for appropriate supervision to be provided, but these were not followed, resulting in significant injuries to both residents.