Deficiency in Providing Adequate Closet Space and Privacy
Summary
The facility failed to provide individual closet space with privacy doors for five residents out of a sample of 43. During a facility tour, it was observed that several residents either did not have a closet or had a closet without a privacy door. Specifically, one resident was sharing his closet with others on the floor, and his roommate did not have a closet at all. Another resident had a closet without a door, while his roommate had a closet with a door. Similar issues were noted in other rooms, where some residents had closets without doors, and one resident did not have a closet at all. Interviews with staff revealed a lack of awareness and consistency regarding the closet situation. A registered nurse deferred the issue to the maintenance department, while a certified nursing assistant initially claimed that every resident had their own closet, which would be divided if shared. However, she later acknowledged the absence of closet doors in certain rooms and the lack of a closet for one resident, justifying it by stating that the resident only wore gowns and had no belongings. This inconsistency in staff responses highlights the facility's failure to ensure adequate and private closet space for all residents.
Penalty
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The facility failed to provide individual designated closet space for residents, affecting several individuals. A resident with bipolar disorder and schizophrenia reported that his roommate wore his clothes due to the lack of dividers in the shared closet. Another resident with major depression and anxiety confirmed wearing his roommate's clothing because he could not identify his own. A third resident with adjustment disorder and psychosis found the closet too small and lacking dividers. The facility's policy required private closet space, but this was not followed, as verified by the Administrator and Unit Manager/LPN.
A resident with morbid obesity was not provided with a bed of appropriate size or a comfortable mattress. Observations showed the resident's feet pressed against the footboard and the mattress compressed to the springs, causing discomfort. The resident reported the bed was uncomfortable, and there was no documentation of an assessment for proper fit or comfort.
The facility failed to provide private closet space for 46 residents, resulting in shared closets without separation for clothing. This issue was confirmed during a facility tour and interview with the MD, affecting numerous resident pairs across the facility.
Deficiency in Providing Designated Closet Space for Residents
Penalty
Summary
The facility failed to provide individual designated closet space for residents, affecting three residents directly and potentially impacting three additional residents. The deficiency was identified through record review, observation, and interviews. Resident #17, diagnosed with bipolar disorder, paranoid personality disorder, and schizophrenia, expressed dissatisfaction with his roommate wearing his clothes due to the lack of dividers in the shared closet. The closet was shared by three residents, and clothing was hung randomly without any indication of ownership, leading to confusion and mix-ups. Resident #18, with major depression, anxiety disorder, schizoaffective disorder, and bipolar disorder, confirmed that he sometimes wore his roommate's clothing as he could not identify his own due to the absence of dividers. Similarly, Resident #81, diagnosed with adjustment disorder, major depression, and psychosis, reported that the closet was too small and lacked dividers, making it difficult to store his clothes. The facility's policy required providing each resident with a private closet space, but this was not adhered to, as verified by the Administrator and Unit Manager/LPN during their interview.
Inadequate Bed and Mattress for Resident
Penalty
Summary
The facility failed to ensure that a resident was provided with a bed of appropriate size and a comfortable, intact mattress. The resident, who was admitted with a diagnosis of morbid obesity, was observed with both feet pressed against the footboard and the mattress compressed to the bed springs. The resident expressed discomfort, stating that the mattress and bed were not comfortable, and his buttock was pressing against the springs. There was no documentation indicating that the bed was assessed for proper size or comfort, and the Director of Nursing confirmed the lack of evidence for such an assessment.
Deficiency in Private Closet Space for Residents
Penalty
Summary
The facility failed to provide private closet space separate from roommates' clothing for 46 residents out of 103 rooms reviewed. During a facility tour, it was observed that several pairs of residents were sharing a single closet without separation for their clothing. This deficiency was confirmed through observations and an interview with the Maintenance Director. The affected residents were identified by room numbers, indicating a widespread issue across the facility.
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