Resident Housed in Unapproved Conference Room Without Sink or Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to comply with state regulations requiring that residents be housed only in areas approved for patient housing. One resident was admitted directly into a conference room and remained there from admission through discharge, a total of six weeks. The conference room was located behind the reception desk at the facility entrance, had advertising brochures on the walls, and was separated primarily by a curtain, with the door left open during care at times. The resident’s care plan specifically documented housing in the conference room and noted that staff needed to bring in water and soap for handwashing because there was no sink in the room. The resident had multiple medical diagnoses, including neutropenia, hemiplegia, hemiparesis, functional diarrhea, and heart failure, and had an intact cognitive status based on a BIMS score of 13. Observations showed the resident in a patient bed in the conference room with a bedside commode and bedside table, and the resident reported using a bell to call for help. A CNA confirmed there was no bathroom or sink in the room, that the resident used the commode for bowel movements, and that privacy was difficult to maintain because the room was primarily separated by a curtain and the door was not fully closed during care. Interviews with staff revealed that the resident’s family requested a private room and selected the conference room after being informed it had been used in the past for resident housing. The Admissions Coordinator stated the census listed the resident in a standard room number, but the resident was always physically located in the conference room. The DON acknowledged the conference room was not ideal for patient care due to the lack of a toilet and sink. The current Administrator and former administrator referenced prior CDPH authorization during the COVID-19 pandemic to use the conference room for residents, but neither could provide dates or documentation, and a review of CDPH waivers and AFLs showed no current authorization and confirmed that temporary COVID-19 waivers had been discontinued, while state regulations prohibit housing patients in non-approved areas without temporary permission in an emergency.
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