Failure to Secure Emergency Cart and Shower Room Creates Accident Hazards
Penalty
Summary
Staff failed to ensure that the B Unit was free from accident hazards by not securing the Emergency Cart (E-cart) and the shower room. The E-cart, which contained scissors, IV catheters, and oxygen tubing, was found unlocked and accessible to residents in the day room, with several residents present and unattended by staff. The facility's E-cart policy did not address the need to lock the cart to prevent unauthorized access. Additionally, the shower room was left unlocked and unattended, with shaving razors and a bottle of Cloralen bleach cleaner stored in an unsecured vanity. Several residents were observed walking by the open shower room without staff supervision. Interviews with staff revealed a lack of awareness and adherence to safety protocols. A nurse stated she was unsure if the E-cart should be locked, while multiple CNAs acknowledged that the shower room should have been locked when not in use. The DON confirmed that both the E-cart and the shower room should be secured to prevent resident access to potentially hazardous items, and that the items found in both locations could pose risks to residents if left accessible.