F0689

G

Failure to Maintain Dry Bathroom Floor Leads to Resident Fall and Ankle Fracture

Chicago, Illinois Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident bathroom floor was dry and free of liquid, resulting in a fall with injury. A cognitively intact, morbidly obese resident with epilepsy, vitamin D deficiency, type 2 diabetes mellitus, and hypertension reported that she was walking from her bedroom to a hallway bathroom in the early morning hours when she entered a dark bathroom with no light on and no wet floor sign present. She stated the bathroom floor was very wet with water, and she slipped, fell, and called for help. Staff responded, and CNAs called 911; EMTs transferred her to the hospital, where imaging showed a left ankle trimalleolar fracture with mild posterior displacement of distal fibula fracture fragments, along with deformity, ecchymosis, tenderness, and decreased range of motion.

The DON stated she was informed that the resident slipped and fell on water on the bathroom floor and that the agency RN assigned to the resident that night had reported the bathroom floor was wet. The DON also stated she would expect nursing staff to remove the water from the floor and place a wet floor sign to prevent a patient from falling. A nurse practitioner stated that fall prevention should be in place for all residents, that floors should be free of waste, rugs, or carpets, and that liquid on the floor is a fall risk because residents can slip and fall on it. The unwitnessed fall report documented that the RN heard someone calling for help from the bathroom and found the resident on the floor, reporting pain and exhibiting a limp left foot. The facility’s housekeeper job description included cleaning floors, including damp/wet mopping and disinfecting, in accordance with proper safety precautions, but the report documents that the bathroom floor remained wet at the time of the resident’s fall.