Failure to Prevent Accident Hazards Due to Clutter and Unsafe Materials
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents. One resident with a history of cerebrovascular accident (stroke), dementia, significant cognitive decline, and a history of falls and suicide ideation required substantial assistance with daily activities and was care planned for a clutter-free environment. Another resident with depression and intact cognition exhibited hoarding behaviors, frequently ordering and accumulating items, and refused to allow staff to remove clutter from the shared room. During an observation, the shared room was found to contain multiple accident hazards, including eight wires hanging from a shelf, three electrical extension cords, a bottle of liquid dish detergent poured into a cup on a bed, and a pharmacy medication bag filled with an unidentified white powder, later identified as baking soda. Staff interviews confirmed the hazardous conditions and the ongoing issue with hoarding, which directly placed the cognitively impaired resident at risk for harm. The hazardous environment was acknowledged by both housekeeping and nursing staff.