Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment remained free from accident hazards and did not provide adequate supervision to prevent accidents in two significant instances. In the memory care unit, a slide barrel lock was installed at the top right corner of an exit door leading to a patio. This lock was positioned out of reach for most individuals, including staff and residents, and required fine motor skills and cognitive understanding to operate. No environmental hazard risk assessment was conducted for this lock, and some staff were unaware of its placement. The lock's presence created a situation where residents and staff could be unable to exit in an emergency, potentially leading to entrapment. The facility's policy required exit doors to remain unlocked, and the Life Safety Code mandates that doors be readily operable from the egress side without special knowledge or effort. Additionally, the facility did not address the hazard posed by the path of travel to the designated smoking area, which required residents to cross a busy parking lot. One resident, who was assessed as cognitively intact and an independent smoker, was struck by a vehicle while returning from the smoking area in his wheelchair. The incident resulted in multiple fractures and hospitalization, with the resident experiencing increased pain and dependence on staff for activities of daily living. Staff interviews confirmed that there was no safe pathway or sidewalk from the facility to the smoking area, and residents had to navigate behind parked cars in a busy parking lot. Multiple staff members acknowledged the lack of safety and the absence of staff assistance for residents traveling to the smoking area. Facility policies required ongoing identification of safety risks and environmental hazards, as well as the development of strategies to mitigate or remove hazards when identified. However, the facility did not conduct a risk assessment for the exit door lock or the route to the smoking area, nor did it implement measures to ensure resident safety in these areas. The deficiencies affected all residents in the memory care unit and placed residents who smoked at risk of serious harm.