Failure to Maintain Cleanliness of Tube Feeding Equipment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for a resident who required tube feeding due to cerebral palsy and dysphagia. The resident, who had moderate cognitive impairment and required substantial to maximal assistance with eating, was observed to have an IV pole used for enteral feedings that was visibly dirty on multiple occasions. Specifically, surveyors noted brown, sticky spots on the legs of the IV pole during several observations over the course of a week. Interviews with facility staff, including the Assistant Director of Health Services and the Executive Director, confirmed that the IV pole was dirty and should have been cleaned. It was also revealed that the facility did not have a cleaning schedule or policy for cleaning multi-use equipment, contributing to the ongoing issue with the unclean IV pole used for the resident's tube feeding.