Unsafe Closet and Pest Infestation Result in Resident Injury
Penalty
Summary
Facility staff failed to provide safe and secure clothing and storage closets in a resident's room, resulting in a closet door falling onto a resident who was seated in her wheelchair. The door, which was not properly fastened with the required screws, struck the resident on the right side of her face, causing three abrasions. The closet structure was found to be deteriorating, with separated, chipped, and peeling particle board, and water damage was observed on the ceiling above the closet. The air conditioning and heating system in the building was known to be inoperable, contributing to condensation and further damage to the closet structure. The facility was aware of the need for closet repairs and replacements in other rooms, but did not act quickly enough to prevent the incident. Additionally, the closet in the resident's room was infested with cockroaches, which were observed darting into the closet and cracks in the wall during inspection. The closet's poor condition, including sawdust-like disintegration and water damage, created an environment conducive to pest infestation. The resident involved had a history of stroke with left side weakness, hypertension, chronic heart disease, and was unable to stand alone. At the time of the incident, the resident was cognitively intact, as indicated by a recent assessment. The facility failed to implement an effective pest prevention and control program, as well as timely maintenance to ensure resident safety.