Failure to Remove Rolling Stool Hazard Resulting in Resident Fall and Rib Fractures
Penalty
Summary
The facility failed to ensure the dining/activity room was free from accident hazards when a rolling stool with swivel casters and adjustable height was left in the area, posing a safety risk to residents. A resident with paranoid schizophrenia and moderately impaired cognition, who required supervision for walking more than 10 feet and for sit-to-stand activities, independently ambulated into the activity room where CNA 1 was present and assisting another resident. While CNA 1 briefly turned away, the resident attempted to sit on the unattended rolling stool. As the resident tried to sit, the rolling stool moved out from under her, causing her to lose balance and fall onto her left side. Following the fall, the resident complained of pain to the right hip and left rib area. An SBAR documented that the fall was unwitnessed and that the resident was found lying on her left side. The physician ordered transfer to a GACH for suspected fall with injury, and hospital records indicated the resident was assessed with multiple right rib fractures. The deficient practice had the potential to cause harm to other residents who were in the area where the rolling stool was left unattended.
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