Failure to Maintain Clean and Homelike Environment Due to Catheter Leakage and Odor
Penalty
Summary
The facility failed to provide a clean, sanitary, comfortable, and homelike environment for residents in the 100 Hall, as evidenced by persistent urine odors and inadequate management of urinary catheter leakage. Multiple observations over several days revealed a recurring urine smell in the hallway, front lobby, and a specific resident room, even after attempts to clean and shampoo the carpet. Documentation and interviews confirmed that a resident with a urinary catheter experienced frequent leakage, which resulted in urine soiling the carpet. Family members and staff reported that towels and dignity covers were sometimes used to contain the leakage, but these measures were not consistently effective, and the odor persisted. Staff interviews indicated that the resident involved often refused catheter care and assistance with changing soiled clothing, contributing to the ongoing issue. It was also determined that improper closure of the catheter drainage bag by an aide led to leakage incidents. Despite efforts by Environmental Services to clean the affected areas, the urine odor remained, and the carpet required replacement. The facility did not provide a policy specifically addressing the maintenance of a homelike environment, and the ongoing odor issue was acknowledged by both nursing and administrative staff as a dignity concern for residents.