Failure to Provide Working Clock Limits Resident Choice
Penalty
Summary
A deficiency occurred when the facility failed to provide a working clock for a resident who was cognitively intact and had diagnoses including Parkinson's disease, kidney disease, and diabetes. The resident had a clear view of a clock above the door in their room, which consistently displayed the incorrect time and had a non-moving second hand. The resident reported that the clock had never worked since their admission to the room, and although batteries were replaced, the clock would only function briefly before stopping again. The resident found the broken clock to be an annoyance, especially since it was in their direct line of sight. Multiple staff members, including a LPN and a CNA, were aware of the issue and had either attempted to address it by replacing the battery or reported it verbally to maintenance. However, the problem persisted, and there was no record of a maintenance ticket in the facility's system for the clock. The facility's policy states that residents are entitled to exercise their rights and privileges to the fullest extent possible, but the ongoing issue with the clock was not resolved, impacting the resident's ability to exercise choice and self-determination regarding their environment.
Plan Of Correction
F 561 1.) Resident #67 clock was immediately replaced. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all clocks were in working order. Nursing and Maintenance department were re-educated to ensure that clocks were working in their rooms when completing any tasks. 3.) System change: maintenance will complete weekly rounds to ensure clocks are within working order. 4.) Administrator/Designee will review 5 rooms weekly x 12 weeks then monthly x 3 months to ensure that clocks are within working order. Any non-adherence will result in 1:1 education. All audits will be submitted to the QA committee for review and further recommendations. The administrator will be responsible for ongoing sustained compliance.