Facility Fails to Maintain Sanitary Environment for Residents
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for its residents, as evidenced by observations made by a surveyor. Resident #90 was observed in a recliner with dried brown substances on the sides of the chair on multiple occasions. Despite the presence of facility staff assisting the resident with lunch, the recliner remained uncleaned over several days. The resident's admission record and recent Minimum Data Set (MDS) indicated certain diagnoses, but specific details were redacted. Similarly, Resident #125 was observed in a wheelchair with dried brownish and white substances on the left wheel. The surveyor noted this during lunch assistance, and although a staff member acknowledged the issue and promised to notify housekeeping, the wheelchair remained uncleaned the following day. The resident's admission record and MDS also contained redacted information regarding diagnoses. Resident #124 was observed with an overbed table that had multiple dried brownish spots on the bottom. Despite a housekeeper's claim of a cleaning schedule, the table remained uncleaned. The facility's policy on wheelchair and recliner cleaning was reviewed, indicating a monthly cleaning schedule, but the actual practice seemed inconsistent. Interviews with staff revealed that cleaning was often adjusted based on immediate needs, but the observed deficiencies suggested lapses in maintaining a clean environment.
Plan Of Correction
1/27/25 Element 1 It is the practice of the facility to ensure that all residents reside in a safe, clean, homelike environment. The deficiency was corrected by performing a facility wide sanitization audit of all resident care areas, including overbed tables, wheelchair and Geri chairs; all areas that were identified to be dirty were immediately cleaned. Element 2 All residents are potentially affected by this deficiency. Element 3 The systemic changes that were implemented to prevent this deficiency from occurring again include: increasing sanitization rounds on resident care areas and wheelchairs as part of the facilities Guardian Angel Program. The Guardian Angel program is a comprehensive auditing tool used to identify issues throughout the facility. This program was expanded to include all resident care areas, with special attention to wheelchairs, Geri chairs, and overbed tables, in order to remain in compliance with F584. Additionally, the Housekeeping Director and Administrator make daily rounds to ensure identified issues are corrected in a timely manner. Element 4 To maintain and monitor ongoing compliance, the Guardian Angel/Homelike Environment Audit is being conducted by all Department Heads once a week for two months, then once every other week for two months, and then monthly for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.