Failure to Provide Adequate Toilet Transfer Supports and Safe Bathroom Environment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s bathroom environment was free from accident hazards and that adequate supports were provided to prevent accidents during toilet transfers. The resident was admitted with multiple sclerosis and vision loss, and the admission MDS showed she was cognitively intact with no falls since admission. On the date of the incident, progress notes documented that the resident was found in a private bathroom sitting on her buttocks between the toilet and sink, stating she had been getting off the toilet, lost her balance, and fell, striking her left shoulder on the sink. A subsequent note indicated the fall was unwitnessed and that the resident, who was on Eliquis, was sent to the hospital after reporting she had hit her head. During interviews, a CNA confirmed the resident was expected to call for assistance with transfers, but the resident was found on the floor when the CNA entered with a lunch tray. The resident reported that in the bathroom where the fall occurred, there was only one grab bar on the right side of the toilet, which she used but which caused shoulder pain, and there was no bar on the left side to support her left arm. She also stated she is blind and has leg weakness due to MS. Observation of the prior bathroom showed a non-skid strip on the floor in front of the toilet, but it was placed too far from where her feet would be while seated. In the current bathroom, there was a toilet riser and a right-side grab bar, but no left-side support, and the resident reported that a prior left-arm support device had been removed because its legs were wobbly, leaving her without left-side support. The DON confirmed that a commode with handles over the toilet had been removed due to being wobbly and replaced with a raised toilet seat, and acknowledged there had been no discussion about adding left-side support after that change.
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