Flooring Hazard in Memory Care Unit Leads to Resident Injury
Penalty
Summary
The facility failed to provide a safe environment for residents, staff, and visitors, particularly in the secure memory care unit, where a flooring hazard was present. This hazard was due to an incomplete floor repair in the 200 hallway, which was a high-traffic area. The flooring issue involved a missing clean-out cover that was temporarily covered with a metal sheet and tape, but not properly repaired. This inadequate repair led to a resident tripping and sustaining a serious injury, requiring hospitalization and surgical intervention. The injured resident, who had a history of difficulty walking and other medical conditions, was attempting to detach herself from tape on the floor when she lost her balance and fell. The incident was witnessed by a Certified Nursing Assistant (CNA), who reported that the tape was not holding anything down, and the resident's foot got caught on it. The fall resulted in a significant decline in the resident's ability to ambulate and perform activities of daily living at her prior functional level. The facility's maintenance records showed that the flooring issue was known and documented, but the repair was delayed. The Director of Maintenance (DOM) had attempted temporary fixes and was researching a permanent solution, but the repair was not completed until after the resident's injury. The facility's failure to address the flooring hazard in a timely manner placed other residents, staff, and visitors at risk for serious injury.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Administrator and Director of Maintenance performed environmental rounds, identified areas of concern noted and reported in Electronic Maintenance System. Repairs on all items identified were completed prior to survey exit on Resident # 6 no longer resides in the facility. 2. Identification of other residents having the potential to be affected: Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and hazards. Administrator/Designee rounded facility to survey for environmental hazards; identified environmental concerns reported via Electronic Maintenance System, addressed by priority level, and completed. 3. Actions taken/systems put in place to reduce the risk of future occurrence include: Administrator/Director of Clinical Services/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion; Director of Clinical Services/Designee re-educated staff on Accidents and Supervision Policy; Director of Clinical Services/Designee re-educated staff on Recognizing & Reporting Hazards; Director of Clinical Services/Designee re-educated staff on Redirecting Residents from Environmental Hazards; Director of Clinical Services/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm; initiation and assignment of direct care staff member as Hallway Safety Monitor for secure unit (200 Hall) for additional supervision and hazard identification. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Administrator/Director of Maintenance/Designee will round to ensure facility is free of hazards twice weekly x 8 weeks; then weekly ongoing. Quality reviews will be completed once a week x 8 weeks and then every 2 weeks x 1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Removal Plan
- NHA and Plant Operations Director performed environmental rounds, identified areas of concern, and reported them in the electronic maintenance records system.
- Work orders started in order of priority for hazards causing uneven surfaces, risk hazards, and items with potential to risk resident safety.
- Summoned Corporate Plant Operations support team for assistance.
- Initiated repairs of identified areas of concern.
- Tiles in high traffic area of secure unit (200 Hall) repaired.
- 400 Hall ramp missing carpet tiles replaced with one solid carpet piece.
- Surveyors and NHA completed environmental rounds of the facility noting areas of continued concern.
- List compiled of concerns from environmental tour, all items entered in the electronic maintenance records system.
- 300 Hall clean out with uneven surface repaired.
- 99.5% of all facility staff were educated.
- Initiated and assigned direct care staff member as 'Hallway Safety Monitor' on secure unit (200 Hall) for additional supervision.
- Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and hazards.
- NHA/Designee rounded facility to survey for environmental hazards.
- Identified environmental concerns reported via electronic maintenance records system, addressed by priority level, and repairs initiated and will be ongoing.
- NHA, DCS, and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion.
- DCS/Designee re-educated staff on Accidents and Supervision Policy.
- DCS/Designee re-educated staff on Recognizing & Reporting Hazards.
- DCS/Designee re-educated staff on Redirecting Residents with from Environmental Hazards.
- DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm.
- Initiation and Assignment of direct care staff member as 'Hallway Safety Monitor' for secure unit (200 Hall) for additional supervision and hazard identification.
- A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures.
- NHA/Plant Ops/Designee will round to ensure facility is free of hazards; then twice weekly; then weekly and PRN (as needed) as indicated.
- These audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee by the assigned auditors.