Failure to Maintain Shower Room in Good Repair Resulting in Resident Injury
Penalty
Summary
The facility failed to maintain a resident shower room in good repair, resulting in an unsafe environment for residents. During an interview, a long-term resident reported sustaining a skin tear after their arm rubbed against a jagged edge on a shelf in the shower room. Observation of the shower room revealed that approximately one foot of the laminated edge on the shelf was peeling off, and clear tape had been applied over the edge to create a smoother surface. The nurse unit manager confirmed that the resident had received a skin tear from the sharp edge and that the concern had been logged in the maintenance book, after which the Maintenance Director applied the tape. A review of the resident's medical records showed documentation of a change in condition, specifically a skin tear on the left forearm sustained in the shower. The medication administration note included instructions to monitor and change the dressing every shift. The Maintenance Director reported that he does not conduct routine audits for maintenance issues and relies on concerns being reported in the maintenance log, which he checks several times daily. The deficiency was identified during the survey based on these interviews, observations, and record reviews.