Failure to Maintain Safe and Functional Elevators
Penalty
Summary
The facility failed to ensure that both elevators were maintained in safe operating condition, resulting in ongoing malfunctions and service interruptions affecting all residents. Documentation review revealed a pattern of elevator failures, including both elevators being unresponsive, stuck on various floors, and requiring frequent repairs from November through May. Service invoices detailed repeated issues such as elevators not responding, being stuck with doors closed, low oil sensor trips, faulty switches, and power issues. Preventative maintenance was performed, but problems persisted, with elevator two eventually being taken completely out of service due to motor and starter failures. There was also an incident involving the fire department responding to a reported entrapment, though the elevator was operational upon their arrival. Observations confirmed that elevator two was out of service, and elevator one was only partially functional. Elevator one required users to manually press the button to return it to the first floor after use on the second floor; otherwise, it would remain on the second floor, causing delays for residents and staff. Staff interviews corroborated these issues, with multiple LPNs and the DON acknowledging the malfunction and the impact on residents, including one resident who could not fit into elevator one due to the size of their wheelchair. Activities were primarily held on the second floor, further complicating access for residents with mobility needs. Maintenance and elevator repair staff interviews indicated a lack of timely communication and follow-up regarding the ongoing issues, particularly with elevator one. The elevator repair supervisor and maintenance director were not consistently aware of the problems, and there was confusion about whether an electrician was needed for power issues. The facility posted signs instructing users to send the elevator back to the first floor, and staff were in-serviced on this workaround, but the underlying mechanical and operational deficiencies remained unresolved at the time of the survey.