Failure to Maintain Safe Environment Due to Water Leak and Improper Equipment Storage
Penalty
Summary
The facility failed to provide a safe environment in accordance with its own policies and procedures in two specific instances. First, a resident with a history of hypotension and anxiety disorder, who was dependent on assistance for most activities of daily living but able to walk to the bathroom independently, remained in a room where water was leaking from the ceiling during heavy rain. The resident's roommate was moved out due to the leak, but the resident was not relocated. Staff interviews confirmed that a tall bucket was placed to catch the water, but no safety cones or hazard signs were present, and the resident could have slipped on the wet floor or tripped over the bucket. The Director of Nursing acknowledged that the resident should have been moved and that additional safety measures, such as floor mats and signage, were not implemented. Second, a Hoyer lift and a shower chair were left in the hallway outside a resident's room for several hours, with the Hoyer lift's legs expanded and facing the hallway and the shower chair placed directly across from it. Staff interviews indicated that these items should have been stored in designated areas, such as the rehabilitation department or shower room, to prevent them from becoming trip hazards. The Director of Nursing confirmed that leaving these items in the hallway created accident hazards for residents and staff. Facility policies reviewed indicated a requirement to maintain a safe environment and minimize accident hazards, which was not followed in these instances.