Failure to Prevent Resident Access to Hazardous Areas and Unsafe Generator Maintenance
Penalty
Summary
Facility staff failed to maintain a safe environment free from accident hazards, resulting in a finding of Immediate Jeopardy for one resident and potentially others. A resident with multiple medical diagnoses, including heart failure, diabetes, and a history of major depressive disorder, was observed independently accessing hazardous areas outside the rear of the building. These areas included a large, unsecured biohazard bin containing dirty containers, an open generator with exposed mechanical parts and tools, and a collection of paint cans and wooden pallets with exposed nails. The resident was able to open and reach into the biohazard bin and was aware of its contents, as indicated by his statements to staff. Staff interviews confirmed that the resident had been accessing these hazardous areas for approximately three weeks, and staff had made multiple unsuccessful attempts to prevent this behavior through education and verbal redirection. Additional observations revealed that the walkway leading to the rear entrance was cluttered with sharp machinery panels, cardboard, and other debris, and that the mechanical room was unsecured, lacking a doorknob or lock, allowing residents unrestricted access. The mechanical room itself was cluttered with tools, sharp objects, electrical cords, and lawn equipment. Staff interviews indicated that maintenance personnel were aware of the need for a new doorknob and lock for the maintenance room door but had not yet addressed the issue. Clinical record reviews documented repeated staff interventions to educate the resident about the dangers of accessing hazardous areas, but the resident continued to do so despite these efforts. Unrelated to the Immediate Jeopardy, an additional deficiency was identified regarding the facility's generator. The exhaust pipe leading from the generator had a large rusted-out hole at the level of a window vent, which could potentially allow carbon monoxide fumes to enter the building. The Maintenance Director acknowledged the issue upon observation and recognized the potential for hazardous fumes to leak into the facility. The state Life-Safety department was notified, and a temporary fix was put in place until the exhaust pipe could be properly replaced.