Failure to Maintain Safe and Functional Patient Care Equipment
Penalty
Summary
The facility failed to maintain mechanical and electrical patient care equipment in safe operating condition for multiple residents, resulting in delayed care and unsafe conditions. Several residents who were dependent on staff and equipment for transfers, such as those with multiple sclerosis, Parkinson's disease, and severe cognitive impairment, experienced issues with stand lifts and mechanical lifts. Specifically, two residents reported frequent problems with lift batteries dying during transfers, causing delays and leaving them in uncomfortable or unsafe positions while staff searched for working batteries. Staff and residents both confirmed that these battery issues were ongoing and not isolated incidents. In another instance, a resident's bed was found to be malfunctioning, unable to lower to the required safety position. Multiple staff members acknowledged the bed's malfunction, noting that it had been an issue for at least several days to over a week before a work order was finally submitted. The bed's inability to lower posed a safety concern, especially as the resident was dependent on staff for transfers and had a history of stroke and limited mobility. The maintenance staff only became aware of the issue after the work order was placed, despite several staff being aware of the problem earlier. Additionally, observations of two other residents being transferred with a mechanical lift revealed that one of the lift's wheels would come off the ground during use, causing the lift to tilt and creating an unstable transfer environment. Staff confirmed that this tilting had been occurring for some time, and they sometimes had to physically stabilize the lift during transfers. Maintenance staff were not aware of this issue until it was brought to their attention during the survey. Review of facility work orders indicated a lack of documentation for these recurring equipment problems, suggesting that the reporting and maintenance system was not effectively capturing or addressing all equipment safety concerns.