Failure to Maintain Clean and Properly Managed Privacy Curtains
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a safe, clean, and comfortable environment when multiple resident room privacy curtains were observed to be visibly soiled or stained. In one room, the privacy curtain had multiple brown stains smeared along its length, and in another room, the curtain had a large brown smear. Staff interviews revealed inconsistent understanding and execution of responsibilities for identifying, changing, and ordering replacement privacy curtains. The Housekeeping Manager stated that stained curtains are supposed to be addressed and swapped out right away, that CNAs or housekeeping staff notify him of dirty curtains, and that he attempts to check all curtains weekly. However, he acknowledged that he does not keep a formal log of curtain changes and instead notes needed changes on a notepad or scrap paper, and he stated that the majority of curtains are stained rather than dirty. Further interviews showed confusion and lack of formal tracking regarding who is responsible for ordering replacement privacy curtains. The Nursing Home Administrator initially stated housekeeping is responsible for putting in orders for new curtains, while the Director of Operations, District Manager, and Housekeeping Manager later stated that central supply is responsible for ordering curtains after being advised of the needed quantity. Central supply staff, however, reported that it is not their responsibility to make privacy curtain orders and that calls are made to a regional company, housekeeping, or maintenance instead. A CNA reported that privacy curtains are sometimes not changed right away despite requests. The DON stated that housekeeping is expected to be notified immediately when curtains appear dirty so they can be switched out right away, acknowledged that curtains are not expected to be or appear dirty after viewing photo evidence, and noted there is no way to determine when a curtain is stained versus soiled. The facility’s Environmental – Cleaning policy requires a clean, safe, orderly, comfortable, and attractive environment, including maintaining walls and ceilings free from dirt or other matter and providing fresh, clean, odor-free linens as needed. Photographic evidence of the stained curtains was obtained.
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