Failure to Prevent Accident Hazards and Maintain Safe Environment
Penalty
Summary
Staff failed to implement safety measures for residents at risk of injury, as evidenced by multiple direct observations and staff interviews. During a continuous observation, the shower room door in the South Hall was left open with the water running and the floor visibly wet, while several residents, including one with severe cognitive impairment and hemiplegia, were present in the hallway. Surveyors had to position themselves near the shower room to prevent this resident from wandering into the hazardous area. Additionally, hallways throughout the facility were heavily cluttered with wheelchairs, mechanical lifts, and carts, further impeding safe passage for residents. Staff interviews confirmed that the shower room door should not have been left open, especially with the water running, and acknowledged the hazard this posed to cognitively impaired residents. Staff also recognized the ongoing issue of hallway clutter, noting the facility's limited space for storage. The Director of Nursing and Administrator both acknowledged these deficiencies, and it was noted that a policy regarding these safety measures was not available for review.