F0689

D

Failure to Maintain Safe Flooring Vents Resulting in Resident Fall and Injury

Fresno, California Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The facility failed to maintain a resident environment free from accident hazards by not identifying, repairing, or replacing unsecured, lifted, or damaged floor vents in multiple resident rooms. One resident, an older male with complex medical problems and multiple comorbidities, had been admitted for short-term and long-term rehabilitation following a large middle cerebral artery (MCA) stroke that resulted in contralateral paralysis, facial drooping, and speech deficits. On the day of the incident, the resident was observed with a bruise under the left eye and an abrasion on the left cheek and reported that he had fallen in his room when his sock became caught on a lifted floor vent as he attempted to walk to the bathroom.

According to the resident, the floor vent in his room had been lifted prior to his fall, and he had previously notified maintenance personnel about the issue, but no action had been taken. He stated that his sock got stuck in the vent, causing him to fall forward and hit his face, resulting in a nosebleed, bruising under the eye, and fear for his safety and eye. The resident reported that after the fall, the maintenance staff entered the room and repaired the vent, and that while staff offered help after the fall, he felt that staff had not cared about his earlier safety concerns when the vent was lifted. He also stated that other rooms in the facility had broken and lifted vents that could lead to injuries to other residents.

Nursing documentation for the incident indicated that a nurse entered the resident’s room during the early morning hours to change his G-tube feeding and observed him attempting to use the restroom. The nurse noted the resident falling and found him lying face down on the floor, with a light nosebleed and a 0.5 cm by 0.5 cm abrasion and bruise under the left eye on the cheek. The resident told the nurse that his sock had gotten stuck in the floor vent as he tried to go to the bathroom, and the nurse documented that maintenance was notified to check the vent and that a slip was placed in the maintenance box. The maintenance supervisor later stated that the corner piece of the vent in the resident’s room had lifted and fallen inside the vent and acknowledged that vents on the floor had the potential to lift, move, or crack, creating safety hazards.

During a facility-wide observation of rooms, seven rooms were identified with floor vents that were lifted, had broken pieces, sharp corners or edges, or were not secured in place. The director of staff development agreed that these vents could pose safety hazards for residents and staff and stated that, to her knowledge, the vents had been in this condition for a long time and that no residents or staff had previously expressed safety concerns. She also stated that some rooms had solid, secured vent pieces while others did not and was unable to explain the discrepancy. The facility’s policies on Safety and Supervision of Residents and Quality of Life–Home like environment stated that the facility strives to make the environment as free from accident hazards as possible, that safety risks and environmental hazards are to be identified on an ongoing basis through training, monitoring, reporting, and QAPI review, and that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions of the floor vents and the resulting fall demonstrated a failure to adhere to these policies.