Failure to Maintain Safe and Functional Resident Environment Due to Wall Damage
Penalty
Summary
A deficiency was identified when a large portion of a resident's wall, measuring approximately three feet wide by two feet long, was found missing beside the right side of the resident's bed. This issue was observed on multiple occasions and confirmed by both staff and maintenance personnel. The resident affected had a history of schizophrenia, seizures, morbid obesity, muscle weakness, transient ischemic attack, gastro-esophageal reflux disease, chronic pain syndrome, and difficulty walking, and was assessed as having severe cognitive impairment. Staff interviews revealed that the damage to the wall had existed for an extended period, though the exact duration was unknown. The certified nurse aide confirmed that such damage would have taken time to develop and acknowledged that staff are responsible for reporting room damage to maintenance in a timely manner. Maintenance staff and the administrator were unaware of how or when the damage occurred and only became aware of it after being informed by staff. The facility began repairs after the issue was reported.