Unsafe and Unclean Environment for Residents
Penalty
Summary
The facility failed to ensure a safe, functional, and clean environment for two residents on the Third Floor B wing nursing unit. During an observation, it was noted that a section of the wall behind one resident's bed had been removed, exposing wires and insulation. This was due to the wall pulling away because of a heavy television. The residents' belongings were scattered throughout the room, allowing debris to fall onto them and into their personal items. The Maintenance Director confirmed the issue, and the Nursing Home Administrator acknowledged the failure to provide a safe and functional environment for the residents involved.
Plan Of Correction
The facility noted the incorrect practices and the situation was addressed immediately. Maintenance staff began repairs as soon as the damage was discovered, and both residents were temporarily relocated to another room to ensure their safety and comfort during the repair process. Their personal belongings were cleaned and restored, and the room was returned to a clean, functional condition upon completion of the repairs. To prevent recurrence, all maintenance projects involving occupied resident rooms will now require advance coordination with nursing and housekeeping staff to ensure resident relocation and item protection prior to work beginning. The TELS system will be the means by which all maintenance repairs are used, including confirming that rooms are vacated and resident property is secured. On April 17, 2025, the Maintenance Director provided in-service education to all maintenance staff on the new protocol for repairs in occupied resident rooms, including the requirement for coordination with nursing and housekeeping, proper resident relocation, and protection of personal items. All work orders will continue to be processed through the TELS system, which now includes confirmation that rooms are vacated and belongings secured prior to any work. To ensure compliance, the Administrator or designee will conduct weekly audits of 2 random maintenance work orders for eight weeks beginning April 21, 2025. Audit results will be reviewed during QAPI meetings, with monthly spot checks continuing thereafter as part of the facility's environmental safety program.