Failure to Ensure Safe Emergency Evacuation for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with significant mobility and medical needs could be safely transferred and evacuated from his room in the event of an emergency. The resident was admitted with diagnoses including lymphedema, Milroy's disease, autistic disorder, attention deficit hyperactive disorder, and expressive language disorder, and was primarily nonverbal and totally dependent on staff for all activities of daily living. Documentation and staff interviews revealed that the resident's weight exceeded the capacity of the available bariatric Hoyer lift, and the facility did not have a lift pad that would properly fit him. As a result, the resident could not be moved out of bed except when transferred to a shower bed, and attempts to reposition him caused elevated heart rate and shortness of breath. Further investigation showed that the resident's bariatric bed was too wide to fit through the doorway of his room, as confirmed by direct measurement and staff interviews. The resident's mother and the Assistant Fire Chief both verified that the bed could not be used for evacuation, and the facility lacked an alternative plan or equipment to evacuate the resident in an emergency. Multiple staff, including the DON, LPN, CNA, and physician, confirmed the inability to use the Hoyer lift or evacuate the resident from his room, demonstrating a failure to provide a safe and accessible environment for the resident.