Missing and Broken Handrails in Facility Corridors
Penalty
Summary
The facility failed to ensure that corridors had firmly secured handrails on three of four nursing units observed, specifically on the B-Wing, C-Wing, and D-Wing nursing units. On the D-Wing nursing unit, several handrails were missing or broken, with tape covering the broken brackets, and one handrail next to the center stairwell door was broken. On the C-Wing nursing unit, the end cover on a handrail was missing, exposing rough and sharp edges, and another handrail was missing between a resident room and the nurses station. On the B-Wing, the handrail beside the nurses station was missing, leaving exposed posts with sharp corners. These observations were confirmed by licensed nurses, Employee E8 and Employee E17, who acknowledged the missing and broken handrails and the potential hazard they posed.
Plan Of Correction
Hand rails have been securely mounted on B, C, and D wing. Hand rails between room 215 and 213 have been replaced. Hand rails between the center stairwell have been replaced and securely mounted. Maintenance will complete an initial audit of all nursing units and order replacement for the damaged/broken hand rails. Maintenance will complete weekly audits x 2 and monthly x 1 to ensure handrails are secured and damage-free. NPE will re-educate staff to add all repair needs to the TELS system. NHA/designee will conduct weekly audits x 2 and monthly x 1 to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee x 3 months.