|Survey Date: 7/31/2007|
Regulation Title: PE: FUNCTIONAL/SANITARY /COMFORTABLE
Regulation Description: The facility is maintained and equipped to provide a functional, sanitary and comfortable environment with an adequate amount of well-lighted space for the service provided.
Based on observations made during tours of the facility from 7/30/07 to 7/31/07 and staff interview, the facility failed to maintain and provide a functional, sanitary and comfortable environment in the peritoneal dialysis (PD) training room. The findings were:
During a tour of the facility on 7/30/07, it was difficult to enter the PD training room. There was a cart in front of the doorway with an empty box on top of it. Just inside the door to the right, there were 34 oxygen containers, size #2, being stored along the wall. Further inside the room there was a cardboard box on the floor that contained new sharps containers. The rest of the room appeared very unkempt and unsanitary.
During the remainder of the survey, various observations revealed no change in the condition of the PD training room.
These findings were brought to the attention of the medical director on 7/31/07 at approximately 11:30 a.m. The medical director agreed the room needed to be ready at all times for interviewing potential PD patients as well as continued training for the PD patients the facility now has.
In summary, the failure to maintain a functional and sanitary environment had the potential to have an adverse effect on all the PD patients.
Facility Plan of Correction:
The PD training room has been cleaned. The oxygen tanks have been removed.
On 8/21/07 a policy was added to the Policy and Procedure manual to ensure that the room remains clean and clutter free the charge nurse on duty will check patient areas at the end of every working day. All staff members have been instructed not to use PD room as storage area.