Failure to Remove Broken Glass Hazard in Behavioral Health Unit
Penalty
Summary
A deficiency occurred when a broken window in a locked behavioral and mental health unit was not promptly repaired or cleaned up, leaving glass shards accessible to all residents on the unit for an extended period. The window was broken by a resident with a history of aggressive behavior, traumatic brain injury, paranoid schizophrenia, and multiple comorbidities. The incident was observed by staff, and the broken glass remained on the windowsill for over three weeks, during which time the area was not secured or made safe for residents. Facility staff, including the Administrator in Training (AIT), were aware of the broken window but did not ensure timely communication or action to address the hazard. The AIT noticed the broken window approximately two weeks before the survey and began an investigation but did not complete it. The maintenance department was not informed of the issue until much later, and there was no documentation or communication in the maintenance thread regarding the broken window. The window was only repaired and the glass cleaned up after the Regional Maintenance Director became aware of the situation during the survey. Interviews with staff and residents confirmed that the broken window was known to facility leadership, but no immediate interventions were implemented to secure the area or remove the hazard. The facility's own policy required prompt reporting, investigation, and corrective action for incidents and accidents, but these procedures were not followed. The failure to address the broken window and remove the glass shards left all residents on the unit at risk of harm.