Failure to Maintain Clean Linens for Resident
Summary
The facility failed to maintain a clean and comfortable environment for Resident #32, as evidenced by the resident having to sleep on blood-stained sheets and in a blood-stained gown following a procedure for an intravenous line. Despite the facility's policy requiring clean and good condition linens, the resident reported that his requests to have the soiled linens changed were ignored by the staff. Interviews with the staff, including a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA), revealed that they either did not notice the blood or failed to report it to the appropriate personnel. The issue was further confirmed by a Registered Nurse (RN) who observed the blood-stained linens the following morning and changed them. The Director of Nursing (DON) and the Administrator both expressed that they expected the staff to ensure linens were clean and not allow residents to remain in soiled conditions. Resident #32, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had been admitted to the facility with a diagnosis of Hemiplegia Following Cerebral Infarction Affecting the Left Nondominant Side.
Penalty
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The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
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