Failure to Maintain Accident Hazard-Free Environment and Equipment Safety
Penalty
Summary
Surveyors identified that the facility failed to maintain a resident environment free from accident hazards for seven residents reviewed for accidents. Specifically, multiple residents who were assessed as high risk for falls and had orders for low beds with bilateral floor mats were found to have furniture or medical equipment placed on top of their fall mats. Observations included chairs, side tables, and bed wheels positioned on the mats, which staff and the DON acknowledged could compromise the mats' effectiveness in preventing injury. Facility policies and manufacturer instructions for the mats explicitly stated that heavy objects should not be left on the mats, as this could cause indentations and damage, reducing their protective function. In addition to the issues with fall mats, two residents were found to have bed controllers with visible, frayed, or exposed wires. Staff interviews confirmed that such conditions should have been reported to maintenance for immediate replacement, as per facility policy. The DON stated that exposed wires on bed controllers are not acceptable and should be addressed promptly to prevent potential harm. Facility policies required the maintenance department to keep all equipment in a safe and operable condition at all times. The residents involved had significant cognitive impairments, including diagnoses such as Alzheimer's disease, dementia, Parkinson's disease, and other conditions affecting their ability to make decisions or care for themselves. Many were dependent on staff for mobility and activities of daily living and had documented histories of falls or high fall risk. Despite these vulnerabilities and the presence of care plans and physician orders intended to mitigate injury risk, the facility did not ensure that environmental safety interventions were properly implemented and maintained.