Failure to Address Flooring Hazards Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate and appropriate protective and support services to prevent accident hazards, resulting in an injury to a resident in the memory care unit. Specifically, the facility did not replace a clean-out drain located in a high-traffic area and failed to address flooring issues promptly and effectively, creating an unsafe walkway. This negligence led to a resident sustaining an injury that required transfer to a higher level of care and surgical intervention. The resident involved had a history of difficulty walking and was independent in some activities of daily living but required supervision for others. The incident occurred near the nursing station and outside the resident's room, where the flooring was uneven due to a concrete patch left by plumbers. The Director of Maintenance (DOM) acknowledged the issue but delayed repairs, attempting temporary fixes that proved inadequate. This resulted in a significant decline in the resident's ability to ambulate and perform daily activities at their prior functional level.
Plan Of Correction
Immediate action(s) taken for the resident(s) found to have been affected include: Flooring was repaired to prevent further accidents. Resident # 6 is no longer resides in the facility. Identification of other residents having the potential to be affected: NHA and Director of Maintenance performed rounds of the facility to identify any hazardous areas. Identified hazards removed and/or repaired. Actions taken/ systems put in place to reduce the risk of future occurrence include: DCS/Designee provided education on Accidents and Supervision policy, redirecting residents with from environmental hazards, and recognizing and reporting potential environmental hazards. An additional staff member has been assigned to memory care unit as Hall Monitor to increase supervision. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Administrator/Director of Maintenance/Designee will complete facility assessment rounds to make certain.