Failure to Maintain Adequate Hand Hygiene Supplies
Penalty
Summary
The facility failed to ensure the availability of disposable paper towels on the second floor, which is a requirement under 42 CFR Part 483, Subpart B, and the 28 PA Code. During a tour of the second floor, it was observed that there were no paper towels in the dispensers in several resident bathrooms, including rooms 235, 212, 255, 217, and the visitor's bathroom across from the nursing station. This lack of supplies is contrary to the facility's hand hygiene policy, which mandates that hand hygiene products and supplies be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Interviews with staff revealed that the issue was known but not promptly addressed. A licensed nurse, identified as Employee E14, reported calling the front desk twice to request housekeeping to replenish the paper towels on the second floor. The facility administrator, Employee E1, confirmed the shortage of paper towels and acknowledged that some dispensers in resident bathrooms and the hall bathroom were empty. This deficiency indicates a failure to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public as required by the regulations.
Plan Of Correction
No Resident were negatively affected by not having adequate supply of paper towels. The facility completed an audit of all resident rooms to identify any areas that did not have paper towels. The Environmental services director was in serviced on the importance of always having adequate supplies in the center. The environmental services department in serviced on ensuring all paper towel dispensers are properly stocked. The Administrator /designee will audit 5 random rooms 3 times per week for 4 weeks then 5 random rooms weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.