Facility Fails to Maintain Clean and Safe Environment on 5th Floor
Penalty
Summary
The facility failed to maintain a clean and safe environment for residents on the 5th floor, as observed on January 23, 2024. A Broda chair located in the hallway outside a resident's room was found to be heavily soiled with a crusty orange substance on the seat, a dried white and brown substance on the footrest, and dirt and debris, including a significant amount of hair, entangled in the rear wheels. Additionally, a fall mat in the resident's room was observed to have large tears, exposing the internal foam. These observations were confirmed by a licensed practical nurse and later acknowledged by the Director of Nursing and the Nursing Home Administrator, who stated that resident care equipment should be maintained in a clean and sanitary manner.
Plan Of Correction
1. The immediate corrective action for the identified Broda chair: the seat, footrest, and wheels were cleaned. Also, the fall mat in room 504 was replaced. 2. EVS Director or designee will conduct an initial audit of all Broda chairs and floor mats to identify other residents who may have the potential to be affected by deficient practice. 3. All EVS staff will be educated regarding the scheduled cleaning of Broda chairs. All nursing staff will be educated to identify and rectify fall mats that are in poor condition. 4. EVS Director or designee will audit all Broda chairs and floor mats weekly for four (4) weeks, then monthly until substantial compliance is achieved. All results will be submitted and reviewed in QAPI.