Failure to Prevent Accident Hazards and Ensure Equipment Safety
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards for two residents. One resident had an unsecured oxygen cylinder lying in the corner of her room since admission, despite not having an order for or using oxygen. Multiple observations confirmed the cylinder remained in the room, and interviews with nursing and administrative staff acknowledged that the oxygen cylinder should have been stored in a designated storage area, not in the resident's room. Facility policy required that gas cylinders be handled only by trained personnel and stored securely, which was not followed in this instance. Another resident, who had a history of falls and required a wheelchair for mobility, experienced a fall due to a loose bolt on the backrest of her wheelchair. The maintenance logs showed no prior work order addressing this issue before the fall occurred. Interviews revealed that there was no established wheelchair safety check system in place at the time, and staff relied on an online referral system to report maintenance concerns. Some staff were not comfortable using the system, and there was no documentation of ongoing wheelchair safety checks for all residents. The facility did not have a policy regarding equipment repair and maintenance, and the lack of systematic checks and secure storage practices led to unsafe conditions for both residents. Staff interviews confirmed that the failures in reporting and monitoring contributed to the deficiencies observed, placing residents at risk for injury due to environmental hazards and equipment malfunction.