F0689

J

Resident Falls Through Laundry Chute Due to Inadequate Supervision and Faulty Door Lock

Cleveland, Ohio Survey Completed on 09-17-2025

Penalty

No penalty information released

Summary

A resident with diagnoses including schizophrenia, dementia, muscle weakness, and difficulty walking, who resided on a secured unit due to aggressive behaviors and risk for wandering, was able to access a locked soiled utility room containing a laundry chute on the third floor. The resident subsequently fell through the laundry chute to the facility's basement, where he was found inside a laundry bin by the Maintenance Director. The only points of entry to the basement laundry chute room were the chute itself and a locked door, confirming the resident's path of entry. At the time of discovery, the resident had visible injuries including bleeding around the mouth and eye, and a large bump on the hand.

Staff interviews and record reviews revealed that the lock on the third-floor soiled utility room had been malfunctioning for approximately a week prior to the incident, and staff, including the former administrator, had been made aware of the issue. Despite the resident's known risk for wandering and the requirement for supervision, the resident was able to leave the secured unit undetected during lunch service. Documentation and investigation into the incident were incomplete and inconsistent, with discrepancies in staff accounts and a lack of comprehensive assessment or immediate summoning of emergency services prior to moving the resident from the scene.

The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent the accident. The resident sustained multiple traumatic injuries, including a C6 compression fracture, an acute T4 anterior fracture, and multiple rib fractures, requiring hospitalization and subsequent transfer to a long-term acute care hospital. The incident affected one of three residents reviewed for accidents, and the facility census at the time was 88.

Removal Plan

• Instructed Licensed Practical Nurses (LPN) #283, #291, #303, and #342 to conduct head counts of their units to ensure all residents were accounted for and had not wandered off their units.
• Checked the soiled utility room containing the laundry chute on the 200 unit to determine if the door was locking properly.
• Checked the soiled utility room containing the laundry chute on the 400 unit to determine if the door was locking properly.
• Checked the soiled utility room containing the laundry chute on the 300 unit to determine if the door was locking properly.
• Coordinated an ad hoc Quality Assurance (QA) meeting to discuss the incident with Resident #51. A root cause analysis was performed, and the team discussed a plan to prevent the incident of a resident wandering into secured places and/or off the unit.
• Decided to re-educate staff on the importance of ensuring the utility room doors were latched and always locked, after each entry and exit, as well as installing an extra lock on each (laundry) chute access on each unit.
• Additional staff training would include ensuring residents on secured units were always supervised and present on their units, ensuring maintenance work orders and all work orders would be placed into TELS (an electronic method for placing, tracking, and communicating work orders that are needed) and emergency orders would be additionally communicated to the Administrator.
• RCSRN #401 and Unit Manager (UM) LPN #287 conducted wandering assessments on 87 current residents.
• Identified 15 residents who triggered as high risk for wandering; the remaining 72 in-house residents were identified as low risk for wandering.
• Installed padlocks on the laundry chute access doors on all three resident care units.
• The DON, ADON #279, UM LPN #253, UM LPN #287, and RCSRN #401 educated all staff on the importance of ensuring utility room doors where the laundry chutes were contained were latched and always locked after each entry and exit.
• Staff were educated that an extra lock had been applied to the chute access doors on each unit and ensuring the padlocks were in a position after each use.
• Staff were additionally educated on ensuring residents on secured units were supervised and ensuring maintenance work orders were placed into TELS and emergency orders communicated to the Administrator.
• All staff education was completed.
• Implemented a plan that all new hires would be educated during orientation by the Administrator or designee on ensuring utility room doors were secured when not in use, the process for submitting maintenance work orders, and ensuring emergency orders were communicated to the Administrator.
• Additional new hire training would ensure laundry chute doors would be always locked when not in use.
• The DON or designee began ongoing audits for all three soiled utility rooms in which the laundry chute access was contained, five days per week, for a duration of four weeks to ensure all doors and chutes were locked and secured appropriately. The results of the audits would be reviewed in the facility's QA meetings.
• The DON or designee implemented ongoing, every shift head counts at the end of each nursing shift to ensure all residents were accounted for. The DON or designee would complete these head counts every shift, seven days per week, for a duration of four weeks. The results of the audits would be reviewed in the facility's QA meetings.