Unsafe and Damaged Toilet Safety Equipment Found in Use
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents when their toilet safety equipment was found in disrepair. Observations revealed that the toilet safety frames in the bathrooms of two residents had cracked and jagged armrests, creating an opening with sharp edges where residents would typically place their hands to stand up. One resident acknowledged the risk, stating that the damaged equipment could cut someone using it. Staff, including a CNA, confirmed they had not previously noticed the damage but agreed it posed a risk for skin tears. The Director of Nursing also observed the cracked armrests and recognized the potential for injury. Both residents involved required assistance with transfers and toileting, and one was noted to be cognitively intact and their own responsible party. The most recent skin assessment for one resident showed no current skin tears or new concerns. The facility's policy requires providing a safe and homelike environment, but the presence of damaged and unsafe equipment in use did not meet this standard at the time of the survey.
Plan Of Correction
F584 1.) Resident #15 & #99 bedside commode was immediately replaced. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all bedside commodes were in working order. Nursing, housekeeping, and maintenance departments were re-educated to ensure that bedside commodes were working in their rooms when completing any tasks. 3.) System change: housekeeping will complete weekly rounds to ensure bedside commodes are within working order. 4.) Administrator/Designee will review 5 rooms weekly x 12 weeks then monthly x 3 months to ensure that bedside commodes are within working order. Any non-adherence will result in 1:1 education. All audits will be submitted to the QA committee for review and further recommendations. The Administrator is responsible for ongoing and sustained compliance.