Failure to Maintain Clean, Safe Shared Shower Environment and Consistent Cleaning Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike shared shower environment, specifically Shower A, and to ensure showers were cleaned and sanitized between residents. A female resident with Parkinson’s disease, Type 2 diabetes mellitus, and muscle wasting, with moderately impaired cognition (BIMS 11) and requiring supervision and set-up assistance for all ADLs, reported that the shared showers were always dirty and not cleaned regularly between residents. She stated she had complained about the condition of the showers for four months without correction, describing broken shower head holders that required her to hang the shower head on grab bars, from which it often slipped to the floor, and characterizing the showers as unsanitary. On observation of Shower A, which served two halls, surveyors noted a ripped/torn shower curtain, missing or broken shower head holders, and disposable gloves on the floor. The resident reported that the shower curtain had been ripped and the shower head holders broken for over a month and that, although a CNA stayed with her to assist with showers, she never saw staff clean or sanitize the shower between residents. The facility’s own policy on a homelike environment required a clean, sanitary, and orderly environment, which was not reflected in the observed condition of Shower A. Interviews with staff revealed inconsistent understanding and implementation of responsibilities for cleaning and sanitizing the showers and for reporting maintenance issues. The Maintenance Supervisor stated he had recently replaced the shower head holders in Shower A based on a verbal report and had no work order or invoice, and he was unaware of the torn shower curtain. LVNs A and B stated CNAs were expected to clean and sanitize showers between residents, with housekeeping performing daily cleaning, and that they monitored CNAs through visual checks and follow-up. However, CNAs gave conflicting accounts: one CNA said CNAs cleaned but did not sanitize showers and reported the shower head holders had been broken for several months and the curtain torn for weeks, adding she did not know how to use the electronic maintenance reporting system; another CNA stated CNAs were responsible for cleaning and sanitizing and that she had verbally reported the broken shower heads and torn curtain two weeks earlier; a third CNA believed housekeeping was responsible for cleaning and sanitizing between residents. The Floor Tech stated housekeeping cleaned showers once per shift and that CNAs were responsible for cleaning/sanitizing after every resident. The DON and Administrator both stated CNAs were responsible for cleaning and disinfecting showers between residents, with housekeeping cleaning once in the morning and once in the evening, underscoring the discrepancy between expectations and actual practice.
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