Failure to Provide Adequate Accommodations for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, leading to deficiencies in care. Resident R251, who was admitted with conditions including respiratory failure, chronic congestive heart failure, type 2 diabetes, and morbid obesity, was not provided with a bariatric bed upon admission. Despite the facility having the necessary equipment, the resident was observed lying in a regular-sized hospital bed, which was too small and caused discomfort. It took three days after admission for the bed to be adjusted to a bariatric setting, during which time the resident required extensive assistance for repositioning. Resident R248 experienced issues with the heating system in their room. The resident was observed sitting in a chair with a sheet wrapped around them due to feeling cold. The heater was initially thought to be functioning correctly, but further inspection by the Regional Maintenance Director revealed that it was not working properly. The heater's safety mechanism was supposed to prevent overheating, but it was confirmed that the unit was malfunctioning, failing to provide adequate warmth for the resident.
Plan Of Correction
1. Resident 251 has been issued a Bariatric bed and mattress to accommodate his needs. Resident 248 heater has been replaced and is functioning. 2. Maintenance Director or designee to conduct an initial audit of residents requiring a bariatric bed to ensure appropriate bed and mattress in place. Maintenance Director or designee to conduct an initial audit of all resident room heaters to ensure proper functioning. 3. NPE or designee to educate maintenance and nursing staff regarding identification of bariatric bed equipment needs and when resident room heaters are not functioning to notify maintenance utilizing TELS platform. 4. The Maintenance Director or Designee will audit weekly for 12 weeks for both PTech units and bariatric mattresses to ensure compliance. 5. NHA or designee to review the results of these audits at the monthly QAPI meeting for 3 months.