Failure to Provide Clean Bed Linens for Two Residents
Penalty
Summary
The facility failed to provide a clean and homelike environment for two residents by not ensuring that their bed linens were changed daily or when soiled. Observations revealed that one resident's bed linen was covered with black and brown spots, and the resident reported that the linens had not been changed for a long time and were not changed daily. A Certified Nurse Assistant (CNA) confirmed the linen was dirty and was unsure when it was last changed, acknowledging that it was not acceptable for residents to lay on soiled linen. The resident's medical history included schizophrenia, anxiety disorder, and unspecified psychosis, and the resident required partial to moderate assistance with activities of daily living (ADLs). Another resident, with diagnoses including chronic obstructive pulmonary disease (COPD), muscle wasting and atrophy, and congestive heart failure (CHF), also had dirty bed linen with dry black and red spots observed. This resident required substantial to maximal assistance with ADLs. A CNA confirmed the linen was dirty and stated that it was facility policy to change linens daily. The Director of Nursing (DON) stated that linens should be changed daily for infection control, prevention of skin breakdown, and resident dignity, and that it was the facility's responsibility to maintain a homelike environment. Facility policies and job descriptions reviewed also indicated the expectation for staff to provide clean linens and maintain cleanliness.