Obstructed Room Entry and Unsecured Exit Door Create Safety Hazards
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards in two key areas: obstruction of a resident's room entryway and inadequate security of an exit door for residents at risk of elopement. In one instance, a Hoyer lift was left positioned directly behind the door of a resident's room, preventing the door from opening fully. This required individuals entering the room to step over the lift's legs and squeeze through a narrow space, despite there being other available areas in the room to store the lift. Staff interviews confirmed that doorways should remain clear to ensure timely assistance in emergencies, and facility policy emphasized the importance of safety during patient handling activities. Additionally, the facility did not ensure that all exit doors were secured to prevent elopement among residents identified as at risk for wandering. One resident with dementia and a history of elopement was observed moving freely throughout the facility, including approaching an exit door in the activity room kitchen that lacked both a wander guard alarm and a locking system. Staff confirmed that this door could be opened from the inside, providing direct access to the outside, and acknowledged that a resident with a wander guard could exit through it. The facility's policy on wandering and elopements did not include procedures for checking the security of all exit doors. These deficiencies were identified through record review, observation, and staff interviews, and involved residents with significant mobility and cognitive impairments. The lack of clear entryways and unsecured exits placed residents at risk for delayed emergency response and potential elopement, as evidenced by a prior incident where a resident exited the facility through a door with a locking failure.