Failure to Prevent Accident Hazards Due to Items Placed on Overbed Light Fixtures
Penalty
Summary
The facility failed to ensure that certain resident areas were free from accident hazards, specifically by allowing personal belongings and other items to be placed on top of overbed light fixtures in the rooms of three residents. For one resident, two picture frames, a hat, and two stuffed toys were observed on top of the overhead light fixture. Staff, including an LVN and the Maintenance Director, confirmed these items were present and acknowledged that such placement could weaken the fixture and potentially result in items falling. The Maintenance Director noted that the resident had recently been transferred to the room and that monthly checks were conducted, but no maintenance request had been logged to address the issue. The DON stated that all staff were responsible for checking resident rooms and ensuring safety, but no action had been taken to remove the items or report the hazard. In two other cases, two pop-up flower cards and a piece of wood were found on top of overbed light fixtures in the rooms of residents with severe cognitive impairment. Staff interviews revealed that CNAs had not noticed or addressed the items, and the Maintenance Director confirmed the presence of these hazards during observations. The Maintenance Director also removed a metal drawer slide bracket from one of the fixtures, stating that no items should be placed on top of overbed light fixtures. Medical record reviews indicated that the affected residents had moderate to severe cognitive impairments, which may have limited their ability to recognize or report such hazards.