Resident Placed in Unclean Room Following Hospital Return
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment when a newly admitted resident was placed into a room that had not been cleaned after the prior occupant left. The resident, who was cognitively intact with a BIMS score of 13, reported that upon returning from a hospitalization and being moved to a different room for isolation, the beds in the new room were dirty and did not appear to have been cleaned. The resident’s family member corroborated this, stating that the room did not appear to have been cleaned or sanitized, noting dirt on the floor, used oxygen tubing on a chair, a cupcake in a container on the overbed table, and food crumbs on the empty bed next to the resident. The family member also reported that the private bathroom toilet appeared unclean, with brown stains resembling feces on the porcelain bowl. The Housekeeping Supervisor stated that resident rooms are supposed to be cleaned daily, including wiping high-touch surfaces with sanitizer, sweeping and mopping floors, emptying trash, and cleaning lavatories and toilets, and that mattresses and bed frames are cleaned twice weekly on shower days. She explained that due to a miscommunication, the housekeeper responsible for the room believed there was more time to clean it, went to lunch, and by the time they returned, the resident had already been placed in the room, which had not been cleaned between the prior resident’s discharge and the new resident’s admission. The Regional Director of Clinical Services/Acting DON and the Administrator both stated that rooms should be cleaned daily and that the room should have been cleaned before the resident was placed there, with the Administrator acknowledging there had been a complaint about this specific room not being cleaned prior to the resident’s return from the hospital. An undated “Deep Cleaning a Room” checklist describes extensive cleaning steps but does not change the fact that the room was not cleaned before the resident’s placement.
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