Failure to Maintain Dry Bathroom Floor Leads to Resident Fall and Shoulder Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain a hazard‑free environment and prevent accidents when a resident’s bathroom floor was wet, leading to a slip and fall. The resident, who had morbid obesity and osteoarthritis, was cognitively intact and required supervision with toileting hygiene, with a documented fall risk and a care plan intervention to maintain a hazard‑free and safe environment. On the morning of 10/19/2025, the resident went to the bathroom, used the toilet, stood up, pulled up her pants, took a step forward, slipped on the wet bathroom floor, and fell, landing on her right arm and shoulder. Following the fall, nursing documentation recorded that the resident reported the floor was wet and that she lost her balance because of it, with right shoulder pain rated 8/10. An LVN who responded to the incident confirmed that the bathroom floor was wet, though not flooded, and acknowledged that floors should not be wet because they are hazardous and can cause residents to slip and fall. The resident reported calling for help without response, then scooting on her back to the bathroom door to open it and call out, after which assistance arrived. The facility’s fall team notes identified the fall as related to an environmental factor, specifically wet floor surfaces, particularly risky for residents with balance limitations. Subsequent clinical records documented ongoing and frequent right shoulder pain over the next several months, with repeated complaints of severe pain and limited ability to raise the arm. An orthopedic consultation noted the resident’s report that she slipped on a slippery bathroom floor while getting off the toilet and had significant right shoulder pain since the fall. An MRI later showed a full thickness tear of the supraspinatus tendon with retraction and fluid in the subacromial and subdeltoid bursa. Facility policies on hazardous areas and falls stated that hazards are anything with potential to cause injury and that staff will try to prevent resident falls with identified interventions, but housekeeping coverage for resident rooms did not extend to early morning hours, and janitorial staff only checked rooms when specifically alerted, contributing to the unaddressed wet bathroom floor.
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