Grab Bar Detachment Leads to Resident Fall and Rib Fractures
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards when a bathroom grab bar used for transfers dislodged from the wall while being used by a resident, resulting in a fall and subsequent rib fractures. The resident had diagnoses including a history of falls, heart failure, and anxiety, and a quarterly MDS showed moderately impaired cognition (BIMS score of 12) but independence with care, transfers, and wheelchair use. The resident’s care plan identified limited physical mobility and risk for falls, with interventions such as staff assistance with daily care as needed, provision of a urinal at night, call bell within reach, and use of non-skid socks. On the evening of the incident, the resident attempted to transfer from a wheelchair to the toilet using the bathroom grab bar, which dislodged from the wall, causing the resident to come down with knees on the floor between the wheelchair and toilet. Initial nursing documentation indicated no immediate injuries, marks, or bruises, and the resident reported no significant pain until several days later, when chest pain developed. A chest x-ray ordered by the APRN identified fractures of the left 5th to 7th ribs, and subsequent nursing notes documented pain management and use of an incentive spirometer. In interviews, the resident reported being permitted to use the bathroom and self-transfer independently, and described grasping the grab bar, its detachment from the wall, and falling with the head against the door before using the call bell for assistance. A nurse aide corroborated finding the resident on the knees on the floor with the grab bar on the floor. The Administrator reported that maintenance conducted monthly environmental rounds and assessed assigned resident rooms, but checking the stability of grab bars had not been part of those rounds prior to this incident.
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