Failure to Maintain Safe Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition for one resident who used a raised toilet seat. Observation revealed that the raised toilet seat was missing an anti-slip rubber foot on one of its legs, causing the seat to rock when weight was applied. The resident, who had dementia, COPD, anxiety, and moderate cognitive impairment, required supervision for transfers and used a walker as her primary mode of mobility. The care plan identified her as being at risk for falls and included the use of a raised toilet seat as an intervention. Interviews with facility staff indicated there was no specific schedule for checking equipment for function and safety. The maintenance director relied on staff to report broken equipment via clipboards and checked these twice daily, but there was no record of the missing anti-slip foot. The DON stated that the maintenance director was responsible for monthly equipment checks and completing work orders, but the administrator confirmed there was no policy regarding the functioning of essential equipment.