Failure to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for Resident R79, as evidenced by persistent offensive odors and unclean conditions in the resident's room. Resident R79, who was admitted to the facility with severe cognitive impairment and multiple medical conditions including anoxic brain damage, pressure ulcers, heart failure, and respiratory failure, was dependent on a feeding tube and required assistance with all activities of daily living. Observations revealed a strong odor of urine and bowel movement emanating from the resident's room, along with a foul sour odor near the resident's bed. Additionally, there was a large puddle of tube feeding formula on the floor and dried spillage on the feeding pole and oxygen concentrator. Despite initial cleaning efforts, the dried spillage on the medical equipment remained, and the foul odor persisted. Subsequent observations confirmed that the strong odors continued to be present in the hallway and the resident's room over several days. Interviews with the Director of Nursing and the Regional Director of Environmental Services corroborated the presence of the odors and the unclean state of the medical equipment. The facility's failure to address these issues resulted in a deficiency related to maintaining a clean and comfortable environment for the resident.
Plan Of Correction
The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulation, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. Resident R79's room was thoroughly cleaned and disinfected. The room is free from offensive odor. A house-wide audit was performed of all resident rooms to ensure that rooms were free from offensive odors. Housekeeping staff will be in-serviced on ensuring that resident rooms are free from offensive odors. The Director of Nursing/Designee will conduct a random audit of five resident rooms weekly for four weeks and then monthly for three months. The audits will ensure that resident rooms are free from offensive odors. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.