Failure to Maintain Clean and Safe Resident Bathroom Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident with Alzheimer's disease, hypertension, urinary tract infection, and insomnia, who was moderately cognitively impaired and required supervision with toileting. Over a period of several weeks, the resident's shared bathroom was repeatedly found to be unclean, with brown substances on the toilet and floor, soiled briefs left in the trash can, and toilet paper and other debris scattered on the floor. These unsanitary conditions were documented through multiple photographs provided by the resident, showing persistent issues such as feces, urine, dirty clothing, and other waste in the bathroom area. Interviews with the resident and her responsible party revealed ongoing concerns about the cleanliness of the bathroom, with reports that the adjoining roommate was contributing to the mess and that the resident often felt compelled to clean the bathroom herself. The resident expressed feelings of stress, being unheard, and a diminished sense of self-worth due to the unclean environment. Staff interviews indicated a lack of clarity regarding responsibility for cleaning after housekeeping staff left for the day, with some staff stating that aides were responsible for cleaning after hours, but also noting that they did not have access to cleaning chemicals, only basic supplies like towels and wipes. Housekeeping staff confirmed that no housekeepers were present after 4 pm, and that aides were expected to clean up messes during those times. However, some nursing staff were unaware of the ongoing issues, and there was no documentation of grievances or concerns in the facility's log until after the situation escalated. The facility's own policies required a clean, sanitary, and orderly environment, and standard precautions for handling soiled materials, but these were not consistently followed, resulting in the resident being exposed to an unclean and potentially unsafe environment for an extended period.