Unsecured Soiled Utility Rooms Accessible to Wandering Residents
Penalty
Summary
The facility failed to prevent access to soiled utility rooms on three units for residents with a history of wandering. Clinical record reviews identified three residents diagnosed with Alzheimer's disease or dementia, all of whom exhibited wandering behaviors and were noted to be oblivious to their own safety. Observations revealed that the soiled utility rooms on each unit could be accessed by simply pushing the door handle, making them easily accessible to residents. Inside these rooms, surveyors found uncovered garbage cans, soiled linen bags, hazardous waste containers, and equipment. On one unit, a specimen refrigerator was found unlocked and placed on an unstable surface, which tipped forward when the door was opened. Other units contained additional hazards such as a vacuum cleaner, a pipe-snaking machine, and a hopper with no lid. Staff interviews confirmed that the potential for wandering residents to enter these rooms had not been previously considered, and the rooms remained unsecured at the time of the observations.