Unrepaired Bedside Commode and Incomplete Fall Investigation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that durable medical equipment, specifically a bedside commode, was maintained in good repair, resulting in a resident fall. The resident had multiple diagnoses including depression, COPD, CHF, severe kyphosis, osteoarthritis, osteopenia, and a history of compression fractures, and was care planned as being at risk for falls related to weakness, incontinence, psychotropic medication use, and prior falls. The resident’s MDS showed intact cognition with a BIMS score of 14, independence with eating, moderate assistance needed for bed mobility and transfers, and dependence on staff for toileting hygiene, with one fall documented in the lookback period. On the day of the incident, the resident experienced a fall while using a bedside commode. Documentation from the emergency room and the facility’s fall packet indicated that the resident had a mechanical fall when she fell through the bedside commode after the bucket fell out, leaving her stuck in the device and yelling for help. The fall packet identified equipment malfunction as a factor, describing that the bedside commode collapsed and that the commode was unstable and had been taped together prior to use. An LPN who responded to the resident’s call for help found the resident folded up in the commode, assisted her out, assessed her, and noted that the thin bar holding the bucket had been taped with surgical tape where it connected to the front of the commode frame, and that this bar gave way when the resident sat down. Staff interviews and observations further established that the commode was mechanically unsecure and had been altered with tape before the fall, and that this condition was known or observable to staff. A CNA reported seeing tape on the bedside commode and stated it was not sturdy equipment, and confirmed that no one from management had asked her for a statement or about who taped or placed the commode in the room. The LPN who completed the fall investigation packet confirmed that no management followed up with her regarding the fall or the condition of the commode. The DON acknowledged that the resident had a fall due to an issue with the bedside commode, was unaware the commode had been taped until reviewing the fall packet, and confirmed there was no investigation into which staff member taped the commode or left it in the resident’s room, nor into what should be done with mechanically unstable equipment. The facility’s fall management policy required the IDT to review all resident falls within 24–72 hours and evaluate and investigate the circumstances and probable cause, but the described follow-up did not include a thorough investigation into the commode’s condition or staff actions related to it.
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