Failure to Maintain Resident Rooms Free of Environmental Hazards
Penalty
Summary
The deficiency involves the facility’s failure to maintain residents’ environments free from accident hazards to the extent possible for three residents with cognitive impairment and mental health diagnoses. One male resident with dementia, severe cognitive impairment, and depression was observed with a can of Lysol spray sitting on top of a 5‑drawer chest in his room. A female resident with major depressive disorder, moderate cognitive impairment, and an impaired cognitive function care plan was observed with a can of aerosol air freshener spray on top of her nightstand. When shown these items, RN A stated that residents were not supposed to have these cans in their rooms because they were a biohazard and dangerous for the residents. Another female resident with dementia, conduct disorder, and severe cognitive impairment, who also had a care plan for impaired cognitive function, was observed lying in bed while pointing to a phone charger cord that she had inserted directly into an electrical outlet without the charging plug attached; the plug was observed separately on top of her 5‑drawer chest. A sign above the outlet requested that staff assist the resident by ensuring her phone was plugged in and turned on. During an interview and observation, RN A and CNA L acknowledged that staff should have connected the resident’s phone to the charger after placing her in bed, and stated the resident could injure herself if she attempted to charge the phone on her own. The Administrator and DON were informed of the situation, and the DON stated staff should have plugged in the charger for the resident and that the resident could have harmed herself by plugging the charging cord directly into the outlet. The facility’s Resident Rights policy stated that residents have a right to a safe, clean, comfortable, and homelike environment and that the facility must ensure residents can receive care and services safely and that the physical layout does not pose a safety risk.
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