Failure to Maintain Clean and Sanitary Resident Room and Equipment
Penalty
Summary
A deficiency was identified when a resident's room and equipment were found to be unclean and unsanitary. The resident, who had diagnoses including anxiety disorder, depression, malnutrition, and adult failure to thrive, was receiving daily enteral feedings via a gastrostomy tube. Observations revealed a dried yellow substance, identified as tube feeding formula, splattered across the walls, ceiling, ceiling light, personal items, and television screen in the resident's room. The tube feeding pump pole and its base were also covered with the same dried substance. These findings were confirmed by an LPN, who acknowledged the extent of the splatter but was unaware of its cause at the time. Further interview with the resident indicated that the splattering occurred when nurses attempted to flush or unclog the gastrostomy tube, causing the formula to spray throughout the room. Despite the initial observation and verification by staff, a follow-up observation several days later found that the room and equipment remained in the same unsanitary condition, with the dried formula still present on multiple surfaces. The ongoing presence of the dried tube feeding formula was confirmed by another staff member during the subsequent observation.