Failure to Ensure Clean and Safe Environment Prior to Resident Readmission
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident who was readmitted from the hospital. Upon the resident's return, the room had not been cleaned prior to admission, as required by facility policy. Observations revealed that the resident's room contained a used bottle of enteral feeding, respiratory supplies, white sand-like debris on the nightstand, a used suction catheter in the nightstand drawer, and debris on the floor and under the bed. Additionally, the second bed in the room was unmade, with stained sheets and a used alcohol swab present. Interviews with staff confirmed that the room was not cleaned before the resident's readmission. The CNA and RN both stated that the room was dirty and disorganized, and neither knew who had placed certain items, such as disinfectant wipes, in the room. The RN admitted to attempting to clean the room herself upon the resident's arrival, as there were no clean sheets on the bed, and she had to use linens from the other bed. The respiratory therapist also confirmed that used suction tubing should have been discarded but was found in the resident's drawer. Further interviews with housekeeping staff and the Housekeeping Director revealed a lack of clear communication regarding the need to clean the room prior to the resident's readmission. The Housekeeping Director stated that rooms should be deep cleaned and disinfected after discharge and before admission, but this process was not followed due to a communication gap. The facility's policy on resident rights affirms the right to a safe, clean, and comfortable environment, which was not upheld in this instance.