Visitor Falls

Service: Risk Management
Subject: Care
Setting: Falls

A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, the ground or other surface (e.g., mat). Injuries sustained by visitor slips, trips and falls can result in significant harm and costs. As a result of provincial and territorial occupiers’ liability legislation (i.e., tort law and legislation concerning the duty of care owed by persons who own or lease property to people who visit or trespass on such property), healthcare organizations may be held liable for visitor slips, trips and falls, especially if they fail to provide a reasonable standard of care in keeping the premises free from hazards. Criteria used to assess occupiers’ liability include whether: a hazard was foreseeable; if there was an adequate system of inspection; and whether the occupier was complying with its system of inspection. Claims from visitor slips, trips and falls can be difficult to defend as the courts view such events as being largely preventable with proper risk management and preventive maintenance practices.

Common Claim Themes

  • Common hazards
    • Uncleared ice and snow;
    • Uneven and deteriorated walking surfaces;
    • Wet and slick surfaces;
    • Curled entrance mats;
    • Missing and loose stair rails;
    • Inadequate lighting;
    • Unsecured construction sites.
  • Frequently involve persons with mobility challenges.
  • Inconsistent incident reporting and investigation procedures. 
  • Limited security camera coverage.
  • Infrequent and undocumented grounds, facility and workplace patrols, maintenance and inspections.
  • Delayed and inadequate response to preventable hazard once identified or reported.
  • Role and responsibility confusion surrounding inspections, maintenance and repairs, including rented and leased premises.
  • Inadequate or extended response to a hazard once identified.
  • Inconsistent use of wet floor signage during floor cleaning.

Documentation

  • Lack of and inconsistent documentation of:
    • Snow and ice removal;
    • Response to spills and reported hazards;
    • Scheduled and as-required grounds, facility and workplace maintenance and inspections.

Case Study 1

A vendor selling goods in the healthcare organization’s lobby slipped on some water and fell. The vendor was brought to the emergency department and diagnosed with a posterior fracture of the elbow, dislocated radius requiring reduction and splinting and a fractured left leg which did not require surgical intervention. The fall was not witnessed but the water was seen by the first person who came to the visitor’s aid. The case was difficult to defend as the healthcare organization did not keep cleaning logs to demonstrate that they followed good housekeeping practices.

Case Study 2

A visitor caught their foot on a rubber seasonal floor mat placed between the inner and outer doors and fell. The visitor was taken to the healthcare organization’s emergency department for assessment where the individual was subsequently diagnosed with a dislocated knee, torn bicipital tendon and meniscus requiring surgery. Additional surgery was required to address peroneal nerve palsy. The visitor required extended physiotherapy and time away from work. The healthcare organization’s mat supplier changed the mat to a heavier version after the fall which was interpreted by the plaintiff that the healthcare organization and the mat supplier should have known that the type of mat in place was too light for the season.

Mitigation Strategies

Snow and Ice Removal Contract

  • Where snow and ice removal is outsourced to a third party, ensure a valid service agreement is in place that includes (but is not limited to):
    • Specific start and end dates; 
    • Insurance provisions (i.e., certificate of insurance from the vendor’s insurer; hold harmless or mutual hold harmless and indemnity clauses; adding the organization as an additional insured on the vendor’s policy);
    • Minimum snow or ice accumulation which will trigger the vendor’s obligation to perform snow and ice removal, and response time;
    • Scope of work and areas where snow and ice removal will occur, including a map of the healthcare organization;
    • Vendor’s 24-hour contact information;
    • Requirement that all work performed is recorded on snow logs. 

Grounds, Facility and Workplace Maintenance and Inspection

  • Adopt a standardized maintenance and inspection policy that includes (but is not limited to):
    • Frequency of maintenance and inspections;
    • How the maintenance and inspections are to be carried out;
    • Who is responsible for performing the maintenance and inspections;
    • How the maintenance and inspections are to be documented;
    • Remedial steps to be followed if the standards are not met.
  • Implement scheduled grounds, facility and workplace inspections including (but not limited to):
    • Daily or per shift rounds;
    • Scheduled biannual or annual interdisciplinary team facility reviews (e.g., review policies, workarounds, interview staff).
  • Adopt a standardized inspection log or form that includes (but is not limited to): 
    • Inspection times;
    • Hazards identified (e.g., condition of walking surfaces, stairs, grip strips, lighting, mats and other possible tripping hazards);
    • Weather/temperature;
    • Snow and ice removal times and locations;
    • Application of salt and/or sand times and locations;
    • Interviews and discussions with staff.
  • Install video surveillance near entrances, stairwells, common and high traffic areas.
  • Adopt a standardized mat program that includes (but is not limited to):
    • Types of mats (e.g., high quality rubber-backed high traction mats; beveled-edge, flat and continuous mats)
    • Location of mats;
    • Application and installation of mats;
    • Care, maintenance and disposal of matting.
  • Adopt a standardized housekeeping program that includes (but is not limited to):
    • Where and how cleaning products are stored;
    • How to immediately contact the housekeeping program;
    • When to use wet floor signs;
    • Frequency for cleaning areas of the facility;
    • Method for cleaning different surfaces and areas.
  • Adopt a formal strategy to reduce parking lot falls that includes (but is not limited to):
    • Posting warning signs and/or barriers where indicated;
    • Marking and repairing damage, spills and oily spots immediately;
    • Keeping lighting and speedbumps (where used) in good repair;
    • Marking tire stops with contrasting or highly visible colour.
  • Adopt a standardized spills response program that includes (but is not limited to):
    • A centralized reporting contact number;
    • Documentation of the call request, responses, causes, clean-up and/or maintenance work;
    • Two-person response where available (e.g., one to guard the spill, second to obtain the cleaning equipment).

Post incident management

  • Implement a standardized post incident management and investigation protocol for reported and witnessed visitor slips, trips and falls that includes (but is not limited to):
    • Assisting the injured visitor in finding medical treatment;
    • Adoption of a standardized incident reporting form that captures key information (e.g., time, location, direction of the travel, name, age, contact information for the visitor, name of the patient being visited where applicable, hazard description and conditions such as footwear, temperature, lighting, witness contact information and statements);
    • Photographing the scene, ground and/or hazard (e.g., photographs of floor cones, seasonal mats, warning signs, footwear and mobility equipment of the visitor prior to clean-up, sanding or salting);
    • Securing and retaining video surveillance in line with the organization’s retention guidelines (where possible, include the 30 minutes leading up to the event);
    • Securing and retaining all incident-related documentation (e.g., incident reports, photographs, and witness statements);
    • Reporting the incident to the insurer;
    • A follow-up process with visitors who have slipped, tripped or fallen to invite them to participate or provide feedback into the review.

References

  • Department of Health and Human Services, Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health (2011). Slip, trip, and fall prevention for healthcare workers
  • Eloszewski JM. (2015). A spill, a slip, a hospital trip. 
  • HIROC (2019). Preparing for winter [newsletter]. 
  • HIROC (2018). Contracts – commercial lease contracts. Risk Note. 
  • Insurance Bureau of Canada (n.d.) Slip, trip and fall. 
  • Insurance Bureau of Canada (n.d.). Slip trip and fall (occupiers liability). 
  • Insurance Bureau of Canada (n.d.). Occupiers’ liability – slip and fall: sample inspection form.
  • Meckbach G. (2019). How slip-and-fall lawsuit rules could change in Ontario [newsletter].