Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for a resident, identified as Resident 106. Observations made over three consecutive days revealed that the resident's tray table was consistently dirty, with a mat on top stained with a red substance. Despite the facility's policy stating that residents have the right to a clean environment, the tray table remained uncleaned. During an interview, the Nursing Home Administrator indicated that housekeeping staff conduct weekly room cleanings, while nursing staff are responsible for daily cleaning of tray tables. However, this responsibility was not fulfilled, leading to the deficiency.
Plan Of Correction
Resident 106's bedside table and mat have been cleaned. Tray tables in all resident rooms have been checked for cleanliness and cleaned as needed. All staff have been educated on resident rights to a safe, clean, comfortable and homelike environment; including cleanliness of bedside tables by nursing staff with care each day. Dirty mats will be discarded and replaced as needed. A QA tool has been developed to review 10% of resident environments weekly to ensure resident rights to a safe, clean, comfortable and homelike environment. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.