Unsupervised Hot Beverage Carts Create Accident Hazard
Penalty
Summary
The facility failed to maintain a resident environment free from potential accident hazards in two of six hallways (2A and 2B). Facility policy prohibits personal beverage heating devices and requires that hot beverages not be left unattended for resident self-service, especially for residents with decreased safety awareness or physical limitations. Despite this, observations revealed that coffee carts containing hot beverages were left unsupervised in the hallways outside resident rooms on multiple occasions. Staff interviews confirmed that residents, including those with Alzheimer's and dementia, were able to access the carts and serve themselves throughout the day without supervision. The facility's CMS-802 form indicated that 24 residents with Alzheimer's or dementia resided on the affected hallways, conditions that can impair memory, judgment, and safety awareness. Multiple nurse aides and a registered nurse acknowledged that the coffee carts were left unattended and that residents frequently accessed them independently. The Director of Nursing confirmed the failure to provide a resident environment free of potential accidental hazards in these areas.