Loose Handrail Identified in Memory Care Hallway
Penalty
Summary
A deficiency was identified when a 10-foot section of handrail between rooms A8 and A10 was found to be loose during an observation. The handrail could be moved back and forth approximately half an inch, with both screws in the middle bracket noted to be loose. The maintenance staff (MS) acknowledged the loose handrail and stated that it had been missed during daily rounds, known as Angel Rounds. The MS was unaware of how long the handrail had been loose and confirmed that it was his responsibility to ensure the facility was well maintained. The Director of Nursing (DON) also confirmed that handrails should be secure and that maintenance was responsible for their upkeep. Further observations revealed that 12 residents were present in the main area of the memory care unit, with one resident using the handrail to pull himself in his wheelchair, another present with a walker, and two residents without assistive devices. A CNA working in the unit was unaware of the loose handrail and believed that residents, primarily in wheelchairs, would not be at risk of injury from the loose rail. Review of the facility's policy confirmed that all handrails are required to be firmly secured and that routine maintenance is the responsibility of the maintenance department.