Failure to Prevent Avoidable Fall Due to Unsafe Bathroom Sink
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, malnutrition, difficulty walking, and cerebral infarction sustained an avoidable fall resulting in actual harm. The resident, who required set-up only for daily hygiene and weighed 115 pounds, was in a shared shower room bathroom when she leaned on the wall-mounted sink. The sink detached from the wall, fell to the floor, and broke into pieces. The resident fell onto a sharp piece of the broken sink, sustaining a five millimeter laceration to her lower back that hemorrhaged and required hospitalization for sutures. Prior to the incident, the resident and other residents had reported concerns about the sink being in disrepair to staff, including the maintenance department. The maintenance director confirmed that no routine maintenance checks were performed on sinks in the facility before the incident. The sink involved was old, wall-mounted, and lacked support legs, being attached only to the wall studs. After the incident, an audit revealed three other similar sinks in the facility. The maintenance director and administrator both confirmed that there were no prior routine checks or reports of disrepair for the other sinks before the audit. The incident was unwitnessed, but other residents responded quickly to the resident's call for help, and staff provided prompt assistance and arranged for emergency medical services. The administrator and maintenance director both acknowledged the sink's failure and the lack of routine maintenance checks. The resident expressed frustration about the ongoing lack of access to a functional bathroom sink following the incident.