Failure to Maintain Safe Walkway Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to ensure that a resident's walkway path in her room was free from accident hazards, resulting in a fall and injury. One resident, who was at moderate risk for falls due to a history of falls, balance problems, and use of an assistive device, attempted to walk through her room using a walker. At the time, her roommate had several visitors, and the visitors were sitting in chairs across the roommate's bed, creating a crowded and cluttered environment with limited walking space. As the resident tried to navigate the narrow space, she tripped and fell. Following the fall, the resident sustained a left ankle and foot fracture, requiring her to be non-weight bearing on her left leg. Interviews with staff, including an LPN and the DON, confirmed that the room was overcrowded and did not provide enough space for safe ambulation. The resident's care plan identified her fall risk and included interventions such as proper footwear, use of a walker, and keeping the call light within reach, as well as ensuring her room was free from safety hazards and clutter. Despite these interventions, the environmental hazard of overcrowding was not addressed at the time of the incident.