ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 19, 2018
Corrected date: January 22, 2019

Citation Details

Based on observation, staff interviews and record reviews conducted during an abbreviated survey (NY 419), the facility did not maintain its residents' Heating and Air Conditioning (AC) equipment in good condition. This was evident in 15 out of 15 residents' rooms that were observed in building 1000 of the facility. The findings are: The Facility's Policy and Procedure on Inspection of Heating and Air Conditioning Systems (AC) dated 01/2018 stated that heating and AC systems will be inspected on a periodic basis and no less than prior to the beginning of each heating and cooling season. Inspections will include the identification of other items which would hamper the efficiency of operation of the AC unit/ system. The facility's Policy and Procedure on Care of Residents' Environment dated 04/2013 stated that window curtains will be washed by housekeeping twice a year or whenever soiled or stained. Surveyor #1 conducted a unit tour on the 4th floor of building 1000 on 11/19/2018 at 10:30AM. Two Heating and AC units were observed in room A401. A plastic bag, bottles of lotion, perfume, soap gel and a Dermalite plastic soap dispenser were observed sitting on the Heating and AC unit to the left side of the room while a large white clock, a large green bag, picture frames and a small white basket were observed sitting on the Heating and AC unit to the right side of the room. These residents' personal items were observed obstructing the airflow from the units. In addition, covering of dark foreign matter was observed on some areas of the front panels of the Heating and AC units. Surveyor #1 with a housekeeping staff conducted a unit tour together on the 2nd floor in building 1000, on 11/19/2018 between 12:43 PM and 1:00 PM. The knobs used to turn the Heat and AC unit on and off, in room A308 were not working and there were no knobs on the Heating and AC unit in room A348. Surveyor #1 together with the Licensed Practical Nurse (LPN) and a housekeeping staff conducted a 2nd floor unit tour in building 1000, on 11/19/2018 between 1:07 PM and 1:20 PM. The Heating and AC units in rooms A210, A215, A220, A226 and A230 were checked for functionality, and the knobs were not working when they were turned to the left and to the right. The front panel of the Heating and AC units and the window curtains in rooms A215, A220 and A230 had dark foreign matter on multiple areas. The front panel of the Heating and AC unit and the window curtains in room A320, A325 and A348 similarly had dark foreign matter on multiple areas. Resident #1 in room A308 was interviewed on 11/19/2018 at 12:57 PM and stated that she was unable to turn the knobs on the Heating and AC unit. The Administrator was interviewed on 11/19/2018, and stated that the housekeeping aide and the housekeeper are responsible for conducting daily rounds and to report any issues found. The maintenance department is responsible for checking all the Heating and AC units in the facility to ensure that they are in good working condition. The Director of Maintenance was interviewed on 11/19/2018 and stated, today is my first day on the job. The Director of housekeeping was interviewed on 11/19/2018 and stated that they do not have any schedule for changing the curtains on the units. Daily rounds of the rooms are done and if there are any issues identified with the curtains, they are immediately addressed. However, if the issues are in respect of concerns with AC units, they are reported immediately to the Director of Maintenance for repairs. The facility does not have any policy or protocol regarding the changing of curtains. The staff does daily checks which are not documented for record keeping purposes. admitted ly, it was his fault that the curtains were in bad condition. The maintenance staff, on the other hand, are supposed to check the Heating and AC units and report any condition observed to be unacceptable. NYCRR 415.29 (a)(1), (h)(1)

Plan of Correction: ApprovedDecember 21, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I what corrective action(s) will be accomplished for those resident found to have been affected by the deficient practice:
No residents have been affected by this practice
-Items have been removed from the AC/Heating units in room A401
-2nd floor in building 1000, the knobs used to turn the Heat/ AC unit on and off in rooms A308, A 248, A210, A215, A220, A226, A230 and A308 have been repaired/replace by Engineering Staff to have the knobs function to increase or decrease the fan speed, However the water temperature will remain the same and cannot be adjusted at individual room units. In heating season the water flows from a central Boiler system and during the AC season the water flows from chiller system.
-The covers on the Heating / AC units have been inspected by the engineering department and cleaned as needed.
-The Director of housekeeping /designee has washed all window curtains in rooms that had been identified: A215, A220, A230, A320, A325 and A348.
II How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
-The Director of Engineering /designee has surveyed the building and developed a list of any AC/Heating units requiring repair of knobs and vent covers to be cleaned.
-The Director of Housekeeping/Designee has surveyed the building and has identified any Curtains that require cleaning/replacement and have assigned housekeeping staff to complete project.
III what measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
-The administrator, Director of Nursing, Engineering, and Housekeeping has reviewed and revised the Policy on Room Terminal Cleaning, Privacy curtains and Heating and Air Conditioning Systems Housekeeping, and Engineering have been re-educated on these policies.
-Director of Staff Development/ designee will educate the nursing staff, maintenance and housekeeping staff on the importance of keeping the AC/Units free of any items and timely reporting any issue with the AC/Heating unit in resident rooms.
-The Director of Housekeeping /designee will have the unit housekeeper include as a part of their daily routine to monitor the cleanliness of room curtains, and AC/Heating Covers, as well as to check that knobs are in place on the AC/Heating units. In the event any non-compliance is identified it will be reported to the Director for immediate correction.
IV How the corrective action(s) will be monitored to ensure the deficient practice will not recur
-The Director of Engineering will develop an audit tool, the Director of Engineering /designee will audit monthly for the next 3 months all AC/Heating units for appropriate function of knobs and cleanliness of the vents covers.
The Director of Engineering /designee will report findings to QAPI committee quarterly for the next 6 months and the frequency thereafter will be determined by the QAPI committee.
-The Director of Housekeeping will develop an audit tool, the Director of Housekeeping /designee will audit monthly for the next 3 months on environmental round that includes room curtains cleanliness.
-The Director of Housekeeping/designee will report finding to the QAPI committee quarterly for the next 6 months and the frequency thereafter will be determined by the QAPI committee.
V The date for correction and the title of the person responsible for correction of each deficiency:
Director of Engineering / Date of completion [DATE].