Failure to Secure Hazardous Areas and Ensure Resident Safety Measures
Penalty
Summary
The facility failed to ensure that areas containing hazardous materials were secured and that accident hazards were minimized for residents, particularly those with cognitive impairments and independent mobility. During an inspection, an unsecured telephone room containing empty boxes and an unlocked wire panel was found accessible on the 200 Hall. Additionally, an uncontained oxygen cylinder was observed sitting directly on the floor in a resident's room. Staff interviews confirmed that the telephone room should have been locked and that oxygen cylinders should not be left unsecured or on the floor in resident rooms. The facility's own policy required that hazardous areas be kept locked and that the environment remain as free of accident hazards as possible. A resident with a history of falls, severe cognitive impairment, and physical limitations was found on two occasions with her call light out of reach, despite care plans specifying that the call light should always be accessible and that staff should orient the resident to its location. Staff interviews confirmed that call lights should be within reach and that all nursing staff are responsible for ensuring this. The facility's policy also required adequate supervision and assistive devices to prevent accidents, but these measures were not consistently implemented, as evidenced by the observations and staff statements.