Failure to Identify and Correct Wobbly Lounge Table Contributing to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure common areas were free of accident hazards and to conduct an adequate post-fall environmental assessment. A resident with an admission date of 12/06/2025 had diagnoses including unspecified fall, other abnormalities of gait and mobility, acquired absence of both legs below the knee, and abnormal posture. On 12/16/2025, the resident was observed in bed with discoloration on the left eyebrow and reported having fallen in the lounge area on 12/14/2025. The resident stated that they stood up from their wheelchair to transfer to a regular chair by holding onto a table in the middle of the lounge, but the table was wobbly and they fell onto their left side. During the same observation, the resident demonstrated how the fall occurred and touched the table, which was noted to be wobbling. On 12/16/2025 at 10:52 AM, a RN (V12) touched the same lounge table and confirmed it was wobbling, stating it was not safe for anyone who would want to sit by it. However, V12 later stated that at the time of the fall she did not check the table and only visually checked the surroundings, and when the resident’s wife called asking if there was any broken furniture where the resident fell, V12 reported there was none based on her visual check. Housekeeping staff (V18) reported that whenever she cleaned the table in the lounge, it was wobbling and that she had informed maintenance about it. The Maintenance Director (V19) stated he was not aware the table was wobbling until the morning of 12/16/2025. The facility’s incident report for the 12/14/2025 fall documented that the resident was observed on the floor sitting, trying to get into a chair in the lounge, and under predisposing environmental factors, “None of the Above” was checked and “Furniture” was not checked. This was inconsistent with the facility’s Fall Prevention and Management policy, which requires an environmental/physical assessment to identify environmental/physical risk factors as part of post-fall management.
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