Failure to Maintain Resident Equipment and Environment Free of Hazards
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for three residents, as evidenced by observations of resident equipment and furniture in disrepair. Two residents were found sitting in wheelchairs with missing right armrest pads, exposing bare metal bars with holes where bolts would be attached. These deficiencies were observed during routine checks, and at the time of observation, there were no visible injuries to the residents' arms. Staff, including an LVN and the DON, were unaware of the missing armrest pads prior to being informed during the survey, and acknowledged that the absence of the pads could lead to skin tears. Another resident was found with a detached headboard and a footboard with missing veneer, exposing rough, raw particle board on his bed. The resident expressed concern about the headboard knocking against the wall and the potential for scraping his leg on the exposed particle board. Staff interviews revealed that the condition of the bed had not been reported or addressed, and the DON confirmed that the bed should be maintained to prevent harm. The Maintenance Director was also unaware of the issue until it was brought to his attention during the survey. Record reviews indicated that there was no facility policy on wheelchair maintenance, and work orders for the missing armrest pads and the bed repairs were not found in the facility's work order records for the relevant period. Staff interviews further revealed that although staff were trained to report broken equipment or furniture, these specific deficiencies had not been reported or had been overlooked, resulting in the continued presence of hazards in the residents' environment.