Failure to Maintain Clean Wheelchairs in Memory Lane Unit
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its units, Memory Lane. During observations, it was noted that two residents' wheelchairs were unclean. On January 6, 2025, Resident R70 was observed lying in bed with a wheelchair beside them that had a dry, white, food-like substance on the seat cushion and bilateral armrests. On January 7, 2025, Resident R1's wheelchair, located in the hallway, was observed with a dried tan substance running down the left side of the seat cushion and base. Later that day, both residents were observed in their wheelchairs, with the substances still present. An LPN confirmed the unclean state of the wheelchairs and acknowledged that they should not be dirty.
Plan Of Correction
R1 and R70's wheelchairs were taken to the wheelchair cleaning station and cleaned. The facility did a whole-house review on all wheelchairs and cleanliness to determine other residents were not impacted. It was determined the facility failed to have a policy in place that addressed maintaining wheelchair cleanliness through the facility. All facility staff have been educated on the process needed to identify wheelchair cleanliness. Facility housekeeping department staff have been educated on the wheelchair cleaning schedule to ensure compliance. The housekeeping manager will monitor all chairs on a given cycle to ensure they are being cleaned timely and as outlined in the policy. The housekeeping manager will review each chair on the cycle as they are to be cleaned weekly for 6 weeks and monthly thereafter. All resident wheelchairs were taken to be cleaned. Education on a new policy to address the cleanliness of wheelchairs as part of a preventative measure has been created by the Nursing Home Administrator (NHA), Director of Nursing (DON), and housekeeping manager. The policy has been reviewed and staff educated. The facility has identified this as a performance improvement program for their Quality Assurance Performance Improvement (QAPI) Program. We will review quarterly with QAPI and track progress.