Failure to Prevent Recurrent Foot Injuries During Transfers and Showering
Penalty
Summary
The deficiency involves the facility’s failure to prevent recurrent right foot and toe injuries to Resident 1 during transfers and bathing activities, despite the resident’s dependence for mobility and toileting. Resident 1, who was admitted with hemiplegia and hemiparesis following a stroke and was assessed as cognitively intact with a BIMS score of 15, was documented on the MDS as unable to walk and fully dependent on staff for mobility and toileting, requiring assistance of two or more helpers. On one occasion, nurses’ notes dated 12/1/26 documented that the resident’s toe was accidentally struck by the bathroom door while he was being assisted out of the restroom, and the resident reported toe pain. CNA 1 later stated that while maneuvering the resident on the commode to exit the bathroom, the resident’s right toes struck the edge of the bathroom door frame and acknowledged she should have been more careful. On a separate occasion, an SBAR note dated 12/4/25 documented that Resident 1 complained of right foot pain following a bump during a shower, and assessment revealed swelling of the right foot. LVN 2 stated that the resident bumped his right foot while being maneuvered in a shower chair in the shower room and confirmed that the resident’s right foot was swollen on assessment. Resident 1 reported that staff repeatedly hit his right foot and toes on the door and bathroom wall while transporting him in the shower chair and commode, causing pain and swelling, and requested that staff take more care during transfers. During record review, the DON acknowledged there was no care plan in place to prevent these recurring right foot and toe injuries and confirmed that no specific interventions had been developed to address this pattern of incidents, despite the facility’s policy requiring implementation of safety procedures and immediate corrective actions to prevent accidents and incidents.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.