Resident Injury Due to Unrepaired Shower Room Tiles
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and diabetic neuropathy, who required dependent assistance with showers, sustained an injury due to loose and missing tiles in a shower room. While being transported out of the shower area by a CNA, the resident's third and fourth toes on the left foot became caught on the uneven tiled area, resulting in lifted and partially removed toenails with moderate bloody drainage. The incident was confirmed by multiple staff interviews and the resident, who reported receiving subsequent evaluation and treatment for the injury. Observations and interviews revealed that the shower room had areas of loose and missing tiles at the time of the incident, which had not been addressed prior to the injury. Facility policy required maintenance of a safe and hazard-free environment, but the presence of the damaged tiles in the shower room constituted a failure to maintain such conditions, directly leading to the resident's injury.