Failure to Maintain Safe Electrical Equipment for Residents
Penalty
Summary
The facility failed to maintain electrical patient care equipment in safe operating condition for three residents. For one resident with Alzheimer's disease, osteoporosis, and a history of falls, a pad/tab alarm intended to alert staff when the resident attempted to get out of bed was found with a broken sensor cord, rendering the alarm nonfunctional. The resident was assessed as high risk for falls and required substantial assistance with mobility and activities of daily living. Staff confirmed that the broken cord meant the alarm would not sound, and the device was not checked for functionality as required. Two other residents, both with severe cognitive impairments and high fall risk, were found to have bed remote controls with frayed or exposed wires. Staff observed the damaged wires and acknowledged that such conditions should not exist near residents. Maintenance staff and the DON confirmed that it was their responsibility to ensure beds and related equipment were safe and that all staff were expected to report any broken equipment to the Maintenance Department. Facility policies reviewed indicated a commitment to maintaining a safe environment, including bed and electrical safety, through ongoing employee training, monitoring, and reporting processes. Despite these policies, the observations and interviews revealed that the required checks and reporting of unsafe equipment were not consistently performed, resulting in the presence of hazardous equipment in resident rooms.