Facility Fails to Maintain Clean and Safe Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for Resident #75, who had multiple health conditions including macular degeneration, legal blindness, dementia, diabetes, and kidney disease. Observations revealed that the resident's room contained a mattress on the floor next to the bed, which was heavily soiled with dried liquid stains, dried food, dusty shoe prints, and white dried material. Additionally, the room had significant damage to the walls, including gouges and missing paint, with exposed drywall and metal corner guards. Interviews with facility staff, including a CNA, RN, Housekeeping Manager, and Maintenance personnel, indicated a lack of effective communication and follow-up regarding maintenance and cleanliness issues. The CNA and RN reported that they would inform the nurse or environmental services about such issues, but there was no evidence of work orders being completed. The Housekeeping Manager acknowledged the responsibility for cleaning the mattress, while the Maintenance staff noted that funding for room repairs had not been secured. The maintenance staff also reported that they were the only maintenance personnel present, which may have contributed to the lack of timely repairs and maintenance in the resident's room.
Plan Of Correction
Element# 1 Medical equipment for resident #75 has been cleaned and sanitized. Gouges, dings, and dents on #75 wall have been repaired. Element# 2 Residents residing at the facility have the potential to be affected. All resident mattresses on the floor have been cleaned and sanitized. Facility Maintenance Technician/designee has audited facility resident rooms and work orders were placed for any rooms found with gouges, dings, and dents. Element #3 Environmental services have been educated on mattress cleaning protocol. Facility Maintenance technician has been re-educated on the process to track and retrieve work orders. Element #4 Environmental Services lead or designee(s), will conduct random weekly audits of medical equipment cleanliness and wall integrity. Audits will be forwarded to the facility QAPI committee for review and further recommendations. Element #5 The Administrator is responsible for sustained compliance.