Failure to Monitor and Maintain Bathroom Door Protector Creates Accident Hazard
Penalty
Summary
Facility A failed to adequately monitor and maintain a resident's bathroom door protector, resulting in a potential accident hazard. A resident with diagnoses including Type 2 diabetes mellitus with hyperglycemia and atherosclerotic heart disease, who was cognitively intact, reported repeatedly hitting her hand on a protruding edge of the bathroom door protector. The issue was reported to the Unit Secretary, who submitted a maintenance work order. The Facilities Management Supervisor applied duct tape as a temporary fix and awaited a replacement door, but did not continue to monitor the interim solution. Subsequent observations revealed that the duct tape was no longer in place, and the door protector continued to protrude, posing a risk to the resident. Interviews confirmed that neither the Facilities Management Supervisor nor the Unit Secretary monitored the effectiveness or presence of the temporary intervention. The resident expressed concern about potential injury, and the deficiency persisted until the new door could be installed.