Failure to Maintain Safe Electrical Environment Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure the resident environment was free from accident hazards, specifically related to electrical safety. One resident, a female with a history of cerebrovascular accident, seizure disorder, anxiety, and depression, and with no cognitive impairment, experienced an electrical shock and burns to her fingers and hand after plugging in her phone charger to a wall socket. The incident was documented in progress notes, and photographic evidence showed burns and blisters on the resident's hand, as well as a charred electrical outlet and wall. The resident reported pain and anxiety following the incident, and other residents and staff confirmed seeing the injuries and the damaged outlet. The facility's records did not include an incident report for this event, and the incident/accident log showed no similar incidents during the relevant timeframe. Interviews with staff and residents revealed that the electrical outlet in the resident's room was loose, charred, and missing a cover after the incident. The maintenance log indicated that the outlet and breaker were replaced after the event, and an electrician's invoice confirmed that a severed hot wire and defective circuit breaker were found and repaired. Despite these findings, the facility did not have a policy addressing incidents or accidents specifically, and staff responses focused on moving the resident to another room rather than documenting or investigating the injury. Multiple interviews with staff, residents, and the maintenance team highlighted that electrical outlets in resident rooms were sometimes worn out, loose, or prone to sparking, and that these issues were not systematically monitored or reported prior to the incident. The administrator and DON were not fully aware of the extent of the resident's injuries or the details of the incident until questioned by surveyors. The lack of immediate and thorough documentation, investigation, and preventive measures contributed to the deficiency identified by surveyors.
Removal Plan
- All staff in-serviced on the event of any electrical issue or any other hazard; they will immediately place the issue in the maintenance log and follow with phone call to administrator.
- All outlets in resident rooms checked by maintenance director to ensure that they are in working order and do not present a hazard.
- All staff in-serviced on prevention of accidents, incidents and hazards.
- Resident rooms will be randomly audited to ensure electrical outlets are in working order.
- All new hires will be educated on completing maintenance log to report any electrical issues or any other hazard with follow up call to administrator.
- Administrator/Designee will be responsible for monitoring the implementation and effectiveness of in-service.
- Administrator/Regional Director of Operations/Maintenance Director/designee will check rooms to ensure outlets are in working order and report any adverse findings during QAPI.
- Administrator/Maintenance Director/designee will check maintenance log to check for any new risk/electrical issues and report any adverse findings during QAPI.
- Medical Director met with the Interdisciplinary team and conducted a QAPI regarding ensuring all resident room outlets were checked to ensure working and not a hazard and all staff educated on accident/incident/hazard prevention, and all staff educated on reporting any electrical issues or other hazards.
- Administrator will be responsible for the implementation of the new process.