Failure to Maintain Safe Shower Room Environment Results in Resident Falls and Serious Injury
Penalty
Summary
The facility failed to ensure a safe environment in the shower room, resulting in two residents suffering falls due to a wet and slippery floor. One resident, with a history of sick sinus syndrome, syncope, hypertensive heart disease, diabetes, anemia, anxiety, coronary artery disease, CVA, and hypertension, required substantial assistance for showering and was at risk for fall-related injury due to a recent pacemaker placement and a non-weight bearing left arm. During a shower, this resident slipped and fell, hitting his head on the wall and floor. The CNA assisting reported the incident, and the resident was initially responsive, but later became unresponsive in bed. Subsequent medical evaluation revealed a large acute subdural hematoma with significant midline shift and uncal herniation, leading to the resident's death after transfer to a major medical hospital. Observations confirmed that non-skid strips were not in place at the time of the fall, and the shower floor was a smooth, slippery fiberglass acrylic surface without additional safety measures such as bath mats or towels. Another resident, diagnosed with respiratory failure, chronic pain syndrome, and major depressive disorder, also required substantial assistance with bathing and had limited lower extremity range of motion. This resident experienced a fall in the shower room while being assisted by an agency CNA unfamiliar with the facility's usual safety practices. The resident slipped on the wet, slippery floor after standing up to be wiped off, and noted that there were no non-skid grippers on the floor at the time. The resident typically wore non-skid socks and expected a towel to be placed on the floor, but these precautions were not taken during the incident. The CNA was unaware of the facility's informal practice of placing a towel on the floor to prevent slipping. Interviews with staff and residents, as well as direct observation, confirmed that the shower room floor became very slippery when wet and lacked adequate non-skid features or consistent use of safety measures. The facility's policies required staff to identify and address environmental fall risks, but these were not effectively implemented in the shower room, directly contributing to the falls and resulting injuries.