Failure to Protect Residents During Fire and Inadequate Emergency Response
Penalty
Summary
The facility failed to protect residents from neglect and did not ensure their right to be free from abuse, neglect, and exploitation, as evidenced by a fire incident on the 400 Hall that resulted in the death of a resident. Staff were unable to timely extinguish the fire and did not assess or render aid to the affected resident after the fire was put out. The resident, who had a history of stroke with left-sided weakness, was dependent on staff for all activities of daily living and required a mechanical lift with two staff for transfers. She was found with severe burns and expired in the facility immediately after the fire. The medical examiner confirmed that the resident had significant burns and soot in her airway, indicating she was breathing during the fire. The facility was aware for over six months that, upon activation of the fire alarm system, control access doors would lock and prevent staff from entering the 400 Hall without a code. During the fire, staff were unable to access the hall for three minutes, leaving only one CNA on the hall with the residents. Security footage and interviews confirmed that staff struggled to open the doors, attempted to enter codes, and were delayed in providing assistance to residents, including the one who was on fire. Some residents were left unattended or not assessed after evacuation, and staff did not know the unlocking mechanisms for the controlled access doors during the emergency. Interviews with staff and the DON revealed that prior to the incident, staff had not been trained on how to respond to residents with severe burns, and no assessment or aid was rendered to the resident after the fire was extinguished. The DON acknowledged that staff should have assessed the resident but did not do so. The medical director stated that staff should have monitored vital signs and breathing and stayed with the resident until EMS arrived. The lack of timely intervention and assessment contributed to the severity of the incident, and the facility's failures affected all residents on the 400 Hall during the emergency.