| 75 |
NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE |
445033 |
1414 COUNTY HOSPITAL RD |
NASHVILLE |
TN |
37218 |
2017-06-13 |
253 |
E |
0 |
1 |
PJSZ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview the facility failed to maintain the residents' rooms, bathrooms, furniture, and equipment in a safe and sanitary fashion for 2 of 4 (Ribeiro and 4th floor Birmingham) nursing units affecting rooms 102, 103, 104, 111, 115, 118, 119, 124 of Ribeiro unit and 402, 413, 415, 427, 429, and 430 rooms of the 4th floor Birmingham unit. The findings included: 1. The facility's Work Orders policy documented, .Maintenance work orders shall be completed in order to establish a priority of maintenance service .Procedure 1. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director. 2. It shall be the responsibility of the department directors or any staff member identifying needed repairs to fill out and forward such work orders to the maintenance director. 3. A supply of work orders is maintained at each nurses' station 4. Work order requests should be placed in the appropriate file basket at the nurses' station. Work orders are picked up daily. Emergency requests will be given priority in making necessary repairs. The facility's Restroom Cleaning policy documented, .PURPOSE: To provide adequate guidelines for cleaning restrooms .The Environmental Services Department will clean restrooms on a daily basis, using the following procedures .X. Showers and Tubs: [NAME] Spray all surfaces with an approved germicidal detergent including walls, curtains, faucets, and shower head, Rinse completely. B. Use a brush to remove soap scrum, if necessary, and rinse . The facility's Daily Cleaning of Patient Room policy documented, .PURPOSE: To insure .proper Infection Control Policy and Procedures in the Environmental Services Department .All resident/patient rooms will be cleaned on a daily basis .Damp dust all horizontal surfaces including, but not limited to over-bed tables, beside tables, baseboard night-light, pictures on walls, top of headboard, top of foot board, telephones, chairs, ledges, light switches, televisions, walkers, I.V. (Intravenous) poles, Geri-chairs, clean, (sic) mirror, soap and towels dispensers, and cabinets with an approved germicidal detergent. Work clockwise around the room .VIII. Clean bathroom according to procedure . 2 Observation of the Ribeiro secured nursing unit , on [DATE] beginning at 2:45 PM thru 3:45 PM, revealed: a. Room 102: A window sill was missing Formica and had missing baseboards A walker was held together with yellow tape that was peeling away from the metal bars. b. Room 103: Shower tiles had unknown black substance in the caulking c. Room 104: Window sill missing Formica d. Room 111: Baseboards missing e. Room 115: Baseboards missing f. Room 118: The lock on the clothes closet was broken which prevented the door from closing securely. g. Room 119 B: There were missing wood pieces which prevented the drawers from closing securely and the foot board on the A bed (near the door) was not securely attached to the bed frame which made it shaky and unstable. h. Room 124: Walls in the bathroom in room 124 were scuffed and in need of cleaning, repair and/or paint. Observation of the 4 th floor Birmingham nursing unit on [DATE] beginning at 4:00 PM thru 4:45 PM, revealed: a. Room 402: Window blinds were torn, bent, and not hanging straight which inhibited the blinds from closing completely, the shower tiles had large blotches of a black substance that resembled mold or mildew, the dresser was broken and in need of repair, and some of the base boards in the bathroom were missing. b. Room 413: Dresser drawer in room 413 was missing the knobs on the 3 top drawers. c. Room 415: The faucet in the sink was leaking and had a continuous line of dripping water. d. Room 427: Bed pan in room 427 was smeared with unknown brown substance and hanging in the bathroom on a metal rack. e. Room 429: A wall, located just outside room 429 was punched in which allowed a large gap between the wall and the base board. f. Room 430: Dresser was broken and the drawers could not close securely. Interview with Licensed Practical Nurse (LPN) # 2 on 4th floor Birmingham on [DATE] at 4:20 PM, LPN # 2 stated, everyone's responsibility to ensure that each resident's room and equipment was cleaned and maintained in a safe and sanitary fashion . Interview with the Facilities Management Director on [DATE] at 4:30 PM confirmed that he was responsible for maintaining each resident's equipment in a safe fashion. The Facilities Management Director stated when staff identified a piece of equipment or furnishings that were in need of repair, they were to complete a work order to ensure that it could be remedied timely. Interview with the facilities Management Director further stated that he had not received any work orders related to these concerns. The Management Director was asked what the procedure was for repairing furnishings and equipment. The Management Director, .if staff do not complete a work order, I would not be aware of the broken equipment and furnishings. Interview with the Environmental Services Supervisor, on [DATE] at 4:45 PM, the Environmental Services Director was asked whose responsibility it was to maintain the cleanliness of the resident's rooms. The Environmental Services Director stated, it was his department's responsibility to clean the residents' equipment and furnishings and his staff must have missed those concerns . Interview with the Administrator, on [DATE] at 10:30 AM, in the Administrator's office confirmed that it was the facility's policy to complete work orders for equipment and furnishings in need of repair. The Administrator stated, .it was our policy to clean and maintain the residents' rooms on a daily basis .the facility staff failed to follow the policies and procedures relative to maintaining the residents' equipment and furnishings and cleaning of the resident's rooms and their belongings on a daily basis . |
2020-09-01 |