Cluttered Resident Room and Overloaded Electrical Outlets Identified
Penalty
Summary
A deficiency was identified when a resident's room was found to be cluttered with multiple personal items surrounding the bed, and eight plugs were connected to two electrical outlets at the head of the bed. The resident, who was alert, oriented, and independent in activities of daily living, had a medical history including type 2 diabetes, acute kidney failure, anxiety disorder, depression, and nicotine dependence. The room environment was observed to be crowded, and the electrical outlets were overloaded, creating a potential safety hazard. Staff interviews revealed that nursing staff were aware of the clutter and had informed the Social Services Director (SSD) and Administrator, transferring responsibility for addressing the issue. The SSD acknowledged awareness of the clutter but was not informed about the multiple plugs in the outlets until the time of the interview. Facility policies reviewed indicated that maintenance is responsible for keeping the building free from hazards and that staff are expected to maintain a safe, clean, and homelike environment.
Plan Of Correction
F-689 Free of Accident Hazards/Supervision CFR(s): 483.25(d)(1)(2) CORRECTIVE ACTION: On 05/22/2025 upon notification, maintenance staff went into Resident 2 room and removed the eight plug that were connected to the two electrical outlets at the head of the bed. Maintenance staff explained to Resident 2 the risk of fire/accident when numerous items are plugged into one outlet. Resident 2 was explained about not using extension cords and was advised to contact maintenance so they can inspect and give clearance before plugging any electrical items. On 05/22/2025 SSA met with the Resident 2 and discussed room being crowded and cluttered. SSA offered to assist Resident 2 in boxing and packaging some of the unnecessary items. On 05/27/2025 an interdisciplinary Conference was conducted with Resident 2. During the conference with Resident 2, room being cluttered and too many electrical items being plugged into receptacle were discussed. There was no ill effect to Resident 2 from this deficient practice. IDENTIFYING OTHER RESIDENTS AT RISK & CORRECTIVE ACTION On 05/23/2025, Maintenance Team conducted spot check on resident's rooms focusing on room environment and electrical items being plugged and connected to electrical outlets in an unsafe manner. On 05/23/2025 Social Service Team conducted a spot check and observation of resident's rooms to ensure they are clutter free. No other residents were identified to be affected by this deficient practice. SYSTEMIC CHANGES On 05/29/2025 Administrator provided In-services to managers that during their weekly Angel Room Rounds to their assigned rooms ensure the appropriate use of electrical items and ensuring resident's surrounding is clutter free. On 05/29/2025 Administrator provided in- service to social service staff related to providing spot check and observation during their routine weekly rounds to ensure the appropriate use of electrical items and ensuring resident surrounding is clutter free. SSA and Maintenance staff will continue monitoring Resident 2 room through weekly inspection for appropriate and proper use of electrical items and to ensure room is clutter free. Any non-compliance with Resident 2 room will be addressed with corrective actions. Maintenance staff, social service staff, managers and administrator will monitor the compliance by conducting weekly spot checks of resident's rooms to ensure appropriate use of electrical items and ensuring residents surroundings are clutter free. Any non-compliance with this requirement will be reported to DON and/or DSD for immediate corrective action and additional training will be provided if deemed necessary. MONITORING EFFECTIVENESS The results of spot checks and inspections will be analyzed by Maintenance Supervisor and/or Administrator and any findings or non- compliance identified with this deficient practice will be reported to the QAPI Committee quarterly for review and further recommendations. Reporting will continue for three months to ensure compliance is maintained.