Failure to Maintain Safe and Comfortable Resident Environment Due to Broken Window
Penalty
Summary
The facility failed to provide a safe and comfortable environment for a resident by admitting and keeping the resident in a room with a broken window, resulting in exposure to cold temperatures for two days and nights. The broken window was not repaired in a timely manner, and the resident was not provided with extra blankets or moved to another room without a broken window. The resident reported feeling very cold and angry due to the conditions, and the room temperature was observed to be very cold during the survey. The resident involved had a history of heart failure, bipolar disorder, and acute respiratory failure with hypoxia. The resident was moderately cognitively impaired but able to ambulate independently and required varying levels of assistance with activities of daily living. Despite these vulnerabilities, the resident was left in a room with a large hole in the window, which allowed cold air to enter and created an uncomfortable and potentially unsafe environment. Facility staff, including the Maintenance Director and DON, confirmed that the window had been broken for several days and that temperature logs were incomplete or unavailable. The Maintenance Director had not ordered a replacement window until the day of the survey, and there was a lack of documentation regarding daily room temperature checks. The facility's own policy required maintenance to keep the building in good repair and free from hazards, but these procedures were not followed in this instance.