Resident Struck by Unit Door and Sustains Nasal Fracture
Penalty
Summary
Staff failed to safely open an access door to a secured resident unit, resulting in a resident being struck by the door and falling. The resident involved had diagnoses including Alzheimer's disease, dementia with behaviors, and osteoarthritis, and was care planned as a fall risk. A recent MDS assessment documented severe cognitive impairment, independent ambulation with set-up assistance, and no falls in the prior 90 days. On the evening of 1/14/2026, the resident was positioned near the corner of the wall and the double doors at the secured unit entrance when a nursing assistant opened the door from the hallway side. The door had a push bar and a clear glass window above it that allowed visibility into the area where the resident was standing. According to nursing documentation and facility incident reports, the nursing assistant did not recognize that the resident was behind the door when she opened it, and the door hit the resident, causing a fall. The resident was found with a nosebleed and facial discoloration but with range of motion at baseline and no reported loss of consciousness. The APRN ordered transfer to the hospital for facial x‑rays, and the resident was diagnosed with a closed nasal bone fracture. Interviews with the DNS, RN, and the nursing assistant confirmed that the resident often paced close to the walls, that multiple residents on the unit wandered or paced near doors, and that the nursing assistant either did not see or did not adequately identify the resident through the door window before pushing the door open, leading to the accident.
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