Failure to Address Hazardous Elevator Door Leading to Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain the resident environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents, specifically related to [NAME] Elevator #5. One resident with polyneuropathy and osteoarthritis, cognitively intact and using a manual wheelchair with staff-supervised self-propulsion, had their arm caught when attempting to stop the elevator door from closing. Nursing progress notes documented that the resident bumped their left arm on the elevator doors and later reported left wrist and forearm pain, with bruising and slight swelling, leading to an orthopedic evaluation that showed no fracture and recommended conservative management. The resident and a sitter both reported that the elevator door did not stop or reopen when the arm was placed across the doorway, and the sitter stated the door had been closing in this manner for approximately five years. Despite this incident, the DON reported that no incident report could be located or had been completed, and there was no documented investigation of the elevator’s door sensor or closing mechanism. A second cognitively intact resident with bilateral lower extremity amputations, who independently navigated the facility in a manual wheelchair, was observed entering [NAME] Elevator #5 when the door closed on the wheelchair, requiring the resident to use an arm to stop the door and reposition the chair. This resident and a CNA both stated that the elevator doors close too quickly, with staff avoiding placing arms in the doorway because the doors will close quickly and “slam shut,” and the resident reporting sometimes needing to stop the doors manually with hands. The Administrator acknowledged awareness that [NAME] Elevator #5 closed quicker than the other elevator and that a resident’s arm had been pinched when attempting to stop the door. The Director of Facilities stated elevators are inspected yearly and not routinely checked, with work orders completed only when problems are reported, and maintenance documentation contained no work order for a door malfunction on this elevator. Multiple prior inspection reports identified violations for [NAME] Elevator #5, and there was no documented evidence that the door sensor or closing mechanism had been tested or repaired following the first resident’s injury.
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