Failure to Maintain Safe Grab Bars and Sanitary Mattress Conditions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment for one resident and a sanitary sleeping environment for another. One resident with a history of falls, heart failure, anxiety, limited physical mobility, and moderately impaired cognition was care planned as being at risk for falls and was allowed to use the bathroom and self-transfer independently. While attempting to transfer from a wheelchair to the toilet using a bathroom grab bar, the grab bar detached from the wall, causing the resident to come down with knees on the floor and head against the door. The resident later reported chest pain, and a chest x-ray identified fractures of the left 5th to 7th ribs. Staff documentation and interviews confirmed that the grab bar was found dislodged on the floor and that prior to this incident, the facility’s monthly environmental rounds did not include checking grab bars for stability. The deficiency also includes the facility’s failure to ensure a sanitary sleeping environment for another resident with diagnoses including congestive heart failure, history of UTIs, and history of pressure ulcers, who was severely cognitively impaired, dependent for all care, and required a mechanical lift with two-person assistance. The resident’s care plan identified a self-care deficit and risk for skin breakdown, with interventions including regular repositioning, incontinence care, and use of barrier cream. A visitor reported that the resident’s mattress sometimes smelled of urine. During an observation with nursing staff, the resident was found incontinent of urine; while the brief did not have an odor, lifting the mattress sheet revealed a strong urine odor from the mattress. Interviews showed confusion among staff about responsibility for mattress cleaning, and facility documentation, including the Cleaning Checklist and Monthly Environmental Round Logs, did not identify a mattress cleaning schedule or checks of grab bar stability.
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