Failure to Maintain Safe Resident Environment and Secure Entrance Threshold
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards when staff did not promptly clean a liquid spill in an ambulatory resident’s room. A resident with recent admission diagnoses including legal blindness and syncope and collapse reported spilling coffee on the floor next to the bed and stated that a staff member had been notified and said she would return to clean it up but had not done so. During an initial observation, the resident was lying in bed with liquid visible on the floor. A subsequent observation showed the resident had transferred independently and ambulated with a walker from the bed to a chair positioned next to the bed while the coffee spill remained on the floor. The facility also failed to ensure that a metal threshold plate at the main front entrance used by residents was properly secured, resulting in a tripping hazard. A complaint had been received stating that the threshold at the first entrance was broken and that a client could not exit with a wheelchair in an emergency situation. Upon observation with the Maintenance Director, the metal transition plate at the entrance threshold had outer edges that were not properly secured, creating gaps between the plate and the floor or ground and causing the plate to shift when weight was applied. The Maintenance Director confirmed that residents use this entrance to exit and enter the building with family or staff.
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