Failure to Remove Known Trip Hazard Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent an injury to a resident. The incident involved a female resident with multiple medical diagnoses, including systemic lupus erythematosus, chronic kidney disease, osteoporosis, hypertension, and anxiety disorder. The resident was cognitively intact and independent in mobility and activities of daily living. She sustained significant bruising and pain after tripping over a rug with an upturned edge in a hallway, striking her head on a doorway. The injury resulted in a large hematoma under both eyes and across the bridge of her nose, requiring evaluation in the emergency room. Prior to the incident, both residents and staff had identified the rug as a trip hazard. The resident council president and other residents had complained to facility administration about the rug, and a family member had also tripped on it, though without injury. Staff, including a registered nurse, reported the hazard to maintenance and administration, and temporary measures such as taping down the rug were attempted. Despite these reports and complaints, the rug was not removed or replaced until after the resident was injured. Documentation in the medical record, incident reports, and interviews confirm that the rug remained in place for several weeks after initial complaints. The facility's fall reduction policy required maintaining an environment as free of accident hazards as possible, but this was not followed in practice. The failure to address the known hazard directly led to the resident's injury, as confirmed by staff, resident, and ombudsman interviews, as well as medical and wound documentation.