Resident Bed Placement by Flood-Prone Exit Door Compromises Living Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when a resident’s bed was positioned so that the head of the bed partially blocked an exit door that was marked as an emergency exit. The resident, who had been admitted with a displaced transverse fracture of the right patella and had moderately impaired cognition, required supervision or touch assistance for ADLs. During observation, the resident was seen hanging a pair of pants and two shirts over a towel on a chair next to the bed. The resident reported that she had been in that bed for about six to seven days and that on the previous day water had flooded the floor near her bed during rain, causing her clothing to become wet, which led her to hang the clothes on the chair to dry. The Maintenance Supervisor stated that the flooding incident was reported to him after it had already occurred and that when he arrived, housekeeping had already mopped and towels had been placed to absorb remaining water. He attributed the flooding to heavy rainwater entering under the exit door and acknowledged that some of the resident’s clothing became wet because she kept belongings on the floor. The exit door in the resident’s room was observed to be unlocked and operable via a push bar leading to a back patio area. The Maintenance Supervisor confirmed that no changes were made to the door to prevent future water intrusion. The DON stated that the flooding near the resident’s bed was reported to her later and acknowledged that having an exit door by the bed could impact the resident’s safety. The Administrator stated that the resident’s belongings would not have been wet if the bed had not been positioned by the exit door.
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