Failure to Secure Second-Floor Windows with Tamper-Proof Limiters
Penalty
Summary
Facility staff failed to ensure that second-floor windows were properly secured to prevent them from opening more than 4 inches, as required to protect confused residents from the risk of jumping out. During an observation with the Administrator, windows in several rooms on the second floor were found without any devices to limit their opening, allowing them to be opened to at least 30 inches. The Administrator confirmed that mechanical limiters should have been in place but were missing. Further interviews revealed that the window limiting devices used were thumb screws, which could be easily removed by staff, residents, or visitors. The Assistant Maintenance Worker (AMW) stated that he checked the windows weekly but did not document these checks, and admitted that he did not measure how wide the windows could be opened during his audits. An audit conducted by the facility found that out of 80 windows, only specific rooms lacked limiters and could be fully opened. Additionally, there was no facility policy regarding the securing and inspection of windows. Further inspection showed that some windows with limiters could still be opened wider than the intended 3 inches, and in one case, a wood screw was used as an improvised limiter, allowing the window to open to 10.25 inches. These findings were confirmed through observation and interviews with facility staff.