Failure to Maintain Non-Skid Flooring for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s room environment free from accident hazards by not ensuring the floor surface provided adequate non-skid traction. The facility’s own Falls and Fall Risk, Managing policy identified environmental factors such as wet floors as contributors to fall risk and required staff to identify interventions based on resident-specific risks. Resident #3, admitted with a displaced mid-cervical fracture of the left femur (subsequent encounter) and unspecified dementia, had a BIMS score of 10 indicating moderately impaired cognition and required partial staff assistance for transfers and ambulation. The resident’s care plan documented a history of falls related to impaired balance and gait, with an intervention for frequent observation and supervised placement when out of bed. The medical record showed multiple falls over several dates, and a fall risk assessment identified the resident as high risk for falls. Surveyor observations on multiple occasions found Resident #3’s room floor to be dry but shiny, slippery, and with little traction along the entry, walkway, and around the bed and recliner. A CNA, housekeeping staff, an LPN, the ADON, the Administrator, and the Housekeeping Supervisor each observed or acknowledged that the floor in this resident’s room was slippery, shiny, and posed a fall risk. The housekeeping staff reported mopping the floor with the facility’s standard floor cleaning solution, and the Administrator stated that the floors had never been waxed and were cleaned with house cleaner, while acknowledging the condition of the floor as a fall hazard. The resident reported that at times the floor felt slippery and at other times felt like glue, causing shoes to stick. Despite the resident’s high fall risk, history of falls in the room and bathroom, and multiple staff acknowledgments of the slippery condition, the floor surface remained in a state that did not provide adequate traction, resulting in an environmental accident hazard for this resident.
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