Infection Control Meeting and Bed Removal Deficiencies
Penalty
Summary
The facility failed to ensure that Infection Control meetings included all the required nine multidisciplinary members, such as the Medical Director, Infection Preventionist, lab, and pharmacy, for all four quarters. This was confirmed during an interview with the Infection Preventionist, Employee E15, on February 11, 2025. The absence of these key members in the meetings indicates a lack of compliance with the required infection control protocols, which are essential for maintaining a safe and healthy environment for residents and staff. Additionally, the facility did not obtain the Department of Health's approval before removing beds from resident bedrooms, as observed during a survey conducted from February 10 to February 13, 2025. Numerous rooms across various wings and floors were found to have fewer beds than they were licensed for, with some rooms containing only bed frames without mattresses or furniture. This was confirmed by the Nursing Home Administrator, who acknowledged the failure to secure the necessary approvals for these changes, potentially impacting the facility's ability to provide adequate accommodations for residents.
Plan Of Correction
1. A correct Roster was sent to the department to ensure the Department roster was accurate. Beds that were available were placed in proper locations. In the event a bed was identified in a location that it shouldn't be, it was removed. Beds were removed in the event they required repair to be re-placed upon repair or replacement. East 3340, 342, 343, 347, 357 will have one bed returned upon repair or replacement. East 4-442, 450 will have one bed returned upon repair or replacement. Grove 1104, 105, 106, 117 will have one bed returned upon repair or replacement. Grove 2 - 202, 203, 205, 209, 215 will have one bed returned upon repair or replacement. Grove 306, 307, 309, 314, 315, 316, 317 will have one bed returned upon repair or replacement. West 103, 107 will have one bed returned upon repair or replacement. West 270 will have one bed returned upon repair or replacement. West 3rd floor was/is used as an isolation unit in the event of a mass population requiring isolation. All rooms have correct number of beds in rooms, unless beds require repair and will be replaced upon repair. Main 306, 312 will have one bed returned upon repair or replacement. Main 405, 411, 416, 428, 430 will have one bed returned upon repair or replacement. Main 504, 523, 527, 530 will have one bed returned upon repair or replacement. 2. The NHA reviewed the bed roster to ensure resident rooms were fitted to the proper number of resident beds. 3. The NHA will review the roster quarterly to ensure resident rooms are fitted to the proper number of resident beds.