Failure to Maintain Homelike Environment Due to Damaged Equipment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents, as observed during a random inspection. Resident 83, who was admitted with Parkinson's disease and other conditions, was found to have a landing mat with a torn portion in their room. This mat was intended to minimize injury due to the resident's high risk for falls, as indicated in their care plan and physician's orders. Despite the visible disrepair, staff did not notify the maintenance department to replace the mat, which compromised the resident's environment. Similarly, Resident 42, admitted with a diagnosis of malignant neoplasm and other conditions, also had a landing mat in disrepair. The mat, which was part of the resident's fall prevention strategy, had a portion ripped off. Staff, including a treatment nurse, confirmed the mat's condition but failed to report it to the maintenance department for replacement. This oversight resulted in the resident not having a homelike environment as required by the facility's policy. Interviews with the Director of Nursing and other staff confirmed that the damaged mats should have been reported and replaced to maintain a homelike environment. The facility's policy emphasizes the importance of a personalized and homelike environment, which was not upheld in these cases. The failure to address the disrepair of essential equipment like landing mats potentially affected the residents' quality of life, as the facility serves as their temporary home during recovery.
Plan Of Correction
F584 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The Maintenance Director/designee removed Resident 83 and 42 floor mats on 2/27/2025. Resident 42 and Resident 83 were provided new floor mats on 2/27/2025. The IDT reviewed and revised Resident 83 and Resident 42 with their current interventions. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: The Nurse Supervisor/designee completed a room audit of all residents on 3/18/2025 to identify residents who may have floor mats in disrepair. No additional residents were identified with floor mats in disrepair. No other residents were affected by the facility's current practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development/designee will re-educate nursing staff on the facility policy Homelike Environment with emphasis on floor mats being in good condition without rips or tears. Re-education will be completed on or before 3/21/2025. The Central Supply Clerk will utilize the device consent audit and special needs/precautions list to ensure all devices and safety precautions are compliant. The Interdisciplinary Team will evaluate residents for the use of floor mats during their comprehensive audits and as needed. Floor mats for resident use will be inspected by the Director of Maintenance prior to being placed in a resident's room. D. How the facility plans to monitor its performance to make sure solutions are sustained: The DSD/Central Supply staff will monitor the floor mats in residents' rooms weekly to ensure they are in good repair without tears or rips. Floor mats identified in disrepair, including tears in the covering, will be removed immediately at the time of observation and replaced with a floor mat in good repair. No other residents were affected by the facility's current practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development/designee will re-educate nursing staff on the facility policy Homelike Environment with emphasis on floor mats being in good condition without rips or tears. Re-education will be completed on or before 3/21/2025. The Central Supply Clerk will utilize the device consent audit and special needs/precautions list to ensure all devices and safety precautions are compliant. The Interdisciplinary Team will evaluate residents for the use of floor mats during their comprehensive audits and as needed. Floor mats for resident use will be inspected by the Director of Maintenance prior to being placed in a resident's room. D. How the facility plans to monitor its performance to make sure solutions are sustained: The DSD/Central Supply staff will monitor the floor mats in residents' rooms weekly to ensure they are in good repair without tears or rips. Floor mats identified in disrepair, including tears in the covering, will be removed immediately at the time of observation and replaced with a floor mat in good repair. The Director of Staff Development will monitor the completion of staff training during new hire orientation, annually, and as needed on the facility's homelike environment practices, including equipment being in good repair. The Director of Nursing/designee will report significant trends identified to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 The Director of Staff Development will monitor the completion of staff training during new hire orientation, annually, and as needed on the facility's homelike environment practices, including equipment being in good repair. The Director of Nursing/designee will report significant trends identified to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F 584 F604 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The pad alarm in Resident 303's room was removed on 2/27/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents using pad alarms in the absence of device/restraint assessment, physician order, and care plan are potentially affected by the facility practice. The DSD/designee completed a room audit of all residents on 2/27/2025 to identify residents who may have pad alarms to verify the presence of a physical device/restraint assessment, physician order, informed consent, and care plan. A total of 149 records were reviewed. Two records were identified without a physician order, informed consent, care plan, or device/restraint assessment present in the medical record. The list of residents with pad alarms identified without a device/restraint assessment, physician order, informed consent, or care plan was provided to the DON for correction on 02/27/2025.