Failure to Honor Resident's Preference Regarding Use of Bleach in Room
Penalty
Summary
The facility failed to honor a resident's expressed preference to not use bleach or bleach-containing products when cleaning her room. Despite the resident's repeated requests over several months to avoid bleach due to its strong smell and the fact that it caused her to cough, staff continued to use bleach products in her room. Housekeeping and environmental services staff were aware of the resident's request and had communicated it to their supervisors, but the information was not consistently relayed to all staff members responsible for cleaning the resident's room. On one occasion, a CNA, unaware of the resident's preference, used a bleach wipe to clean the resident's bedside table, which caused the resident to become upset due to the strong smell. The CNA attempted to mitigate the situation by wiping the area with a wet towel, but the resident remained distressed. Interviews with other staff, including the LVN and DON, revealed that while some staff were aware of the resident's request, there was no formal documentation in the resident's medical record, no physician's order, and no signage in the room to alert all staff to the resident's preference. The resident's medical record indicated a diagnosis of depression and modified independence in decision-making. The lack of consistent communication and documentation regarding the resident's preference led to repeated use of bleach products in her room, resulting in her preference not being honored and causing her distress.