F0689

G

Failure to Prevent Fall After Room Was Mopped Without Wet Floor Signage

Brandon, Mississippi Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an environment as free as possible from accident hazards and to provide adequate supervision and assistance to prevent accidents, resulting in a resident fall with injury. Facility policies titled “Safety and Supervision of Residents” and “Homelike Environment” state that resident safety, supervision, and a safe environment are priorities. Despite these policies, a housekeeper entered a resident’s room at approximately 10:30 AM, found the resident asleep, and proceeded to clean and mop the floor without placing any wet floor signage. The housekeeper reported believing the resident was bedridden and did not expect the resident to get up unassisted, and also stated that no wet floor signs were available and that it was their first time working on the unit.

Progress notes and witness statements document that shortly after the room was mopped, staff heard the resident crying and found her lying face down on the wet floor in a pool of blood, with no wet floor sign in place. The resident sustained multiple injuries, including a 2 cm laceration to the top of the head, a 0.75 cm laceration to the forehead, a 0.25 cm laceration on the bridge of the nose, discoloration and contusions around both eyes, and discoloration to the left knee. A Family Nurse Practitioner documented that the resident was seen on the floor with blood pooled around her head and lacerations to the forehead and nose, with a contusion forming over the left eye. Hospital records further documented facial trauma, an orbital fracture, and suspected concussion, with suturing required for the laceration and imaging confirming an acute orbital blowout fracture of the left orbital floor.

Interviews with staff confirmed that the floor was wet from recent mopping and that no caution signage had been placed. The Director of Nursing stated that the resident was last seen around 10:55 AM and was found around 11:00 AM lying face down on the wet floor, confirming that the housekeeper had assumed the resident was not mobile. A CNA reported having assisted the resident with a shower and returning her to her room, where the resident was sitting up watching television prior to the incident, and later found the resident on the wet floor with no sign present. An LPN described entering the room after hearing the resident crying, stumbling on the wet floor, and finding the resident face down with blood on her face and hair. The Licensed Nursing Home Administrator confirmed that the housekeeper mopped the floor without posting a wet floor sign and that staff did not identify the wet floor as a potential hazard prior to the incident. Record review showed the resident had Alzheimer’s disease, unsteadiness on feet, and documented memory problems with some difficulty in new situations, indicating known cognitive and mobility issues at the time of the fall.