Electrical System Maintenance Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain components of the electrical system on one of four floors. Specifically, on the 2nd floor in Room 224, a receptacle near the A-bed was missing a cover, and in Room 226, the reading light over the A-bed had non-terminated, exposed wiring hanging from the underside of the cover. These deficiencies were identified during an inspection and confirmed in an interview with the Administrator, Regional Director, Regional Maintenance Director, and the Environmental Services Director.
Plan Of Correction
0911 The facility failed to maintain components of the electrical system, on one of four floors. No residents were affected. All residents have the potential to be affected. The 2nd floor Room 224, a receptacle near the A-bed was repaired and a cover was installed as required. 2nd floor Room 226, the reading light over the A-bed had non-terminated, exposed wiring hanging from the underside of the cover. An audit was completed by the Maintenance Director to ensure that all receptacles are installed as required and that all lights are installed as required. Director of Maintenance and maintenance staff were educated by the Administrator on the requirement. Also, maintenance director and maintenance staff were educated on the requirement to audit the receptacles when installed. They were also educated that bedside lights must be inspected frequently for physical integrity. Education of floor staff (Certified nursing assistants, professional nurses, housekeepers) was initiated to report any damaged receptacles and overhead lights to maintenance for repair. The Maintenance Director/Designee will conduct one weekly audit of random receptacles for four weeks, then monthly for two months and then quarterly thereafter. In addition, auditing will occur for any newly installed receptacles and during room deep cleaning. The Maintenance Director/Designee will conduct one weekly audit for overhead lamps for four weeks and then monthly for two months. Additionally, overhead lamps will be audited when a repair or replacement is put in place. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.