Resident Fall and Fractures Due to Unfinished Bathroom Floor With Glue Hazard
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision during bathroom renovations, resulting in an unwitnessed fall with major injury for one resident. The facility’s Fall Prevention Program policy required universal environmental interventions, including a clear pathway to the bathroom, and routine rounding. At the time of the incident, remodeling was underway in the resident’s room and shared bathroom, and the bathroom floor was not yet completed, with glue still present on part of the floor. Residents were not reassigned rooms during the remodeling of their rooms and bathrooms, and the resident continued to use the bathroom that was under construction. The resident involved had diagnoses including Alzheimer’s disease, dementia with anxiety, parkinsonism, and osteoarthritis, and had a BIMS score of 8/15, indicating moderate cognitive impairment. According to the MDS and staff interviews, the resident was ambulatory, independent with toileting, and had not had a fall in over two years. Staff, including the DON and unit manager, stated that the resident did not require assistance with toileting and was considered independent and cognitively fit, so she was not assisted to the restroom during the renovation period. However, the Director of Maintenance confirmed that glue remained on the bathroom floor prior to the fall, and that the resident was known to wear socks. On the day of the incident, a contractor alerted a CNA to the shared bathroom, where the CNA found the bathroom door half open and the resident lying on the floor. EMS and hospital records documented that the resident’s sock or foot became stuck in glue on the bathroom floor, causing her to fall. Multiple staff, including an LPN, RN, and another LPN, confirmed that the bathroom floor was under construction and not completed at the time of the fall. The resident reported pain in her right arm and leg and stated she had hit her head. Assessments and imaging revealed a right humerus shaft fracture, a right open distal femur fracture, a hematoma over the right inferior frontal scalp, a contusion of the knee, and facial swelling, and she subsequently underwent operative fixation for both fractures.
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