Failure to Maintain Safe and Secure Toilet Safety Frames and Commode Bars
Penalty
Summary
The facility failed to maintain toilet safety frames and a bariatric commode in safe operating condition for two residents who required assistive devices for toileting and transfers. For one resident (R70), who had normal cognition, a diagnosis of repeated falls, urinary incontinence, and a care plan requiring staff assistance with toileting, the toilet safety frame in her bathroom was observed to be wobbly and easily moved when grabbed. The manufacturer’s manual for the toilet safety frame required regular checks to ensure it was securely locked onto the toilet before use. R70 reported that the bathroom handrails around her toilet were wobbly and that she had recently fallen off the toilet, which scared her, though she was not injured. Therapy documentation showed that R70 needed grab bars and toilet stabilizer bars for safe toileting with assistance, and both the PT and COTA stated that she definitely needed secure safety handrails and that an unsecure or loose stabilizer bar could contribute to a fall. For another resident (R4), who also had normal cognition, a history of repeated falls, weakness, CVA with left-sided weakness, and impaired mobility, the handrails attached to his bariatric commode were likewise observed to be unsecure and moved easily when grabbed. The bariatric commode manual required periodic visual inspection and weekly checks of all nuts, bolts, and knobs to ensure stability and safe use. R4 reported feeling unsafe on the toilet because the bars moved around too much. His care plan documented difficulty with transfers, risk for falls, and the need for toileting assistance and reminders not to transfer without help, and OT documentation indicated he required adaptive equipment and assistive devices, including a raised toilet seat/3-in-1 commode, for safe toileting. The COTA confirmed that, due to his CVA and left-sided weakness, he most definitely needed toilet stabilizer bars and that a loose stabilizer bar had the potential to contribute to a fall. The Administrator and Maintenance Director stated that quarterly preventive maintenance was done on resident bathrooms and that a checklist existed but was not used for documentation; the Maintenance Director and Mechanic could not provide documentation that the toilet safety frames for these residents had been routinely checked, and only undated “chicken scratch” notes from a prior period were available.
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