Failure to Maintain Odor-Free Environment and Properly Investigate Missing Personal Items
Penalty
Summary
The facility failed to ensure that resident living areas were free from persistent odors, specifically in the rooms of two residents. One resident, with diagnoses including morbid obesity and diabetes, was noted to have a strong, foul odor emanating from his room on multiple occasions. Despite being cognitively intact and generally independent with self-care, this resident often refused staff assistance with personal hygiene, particularly with pericare and cleaning of abdominal folds, which contributed to the ongoing odor. Staff interviews confirmed that the resident's room had a persistent odor, and housekeeping efforts, including deep cleaning and use of odor-blocking products, only temporarily alleviated the issue. The care plan indicated staff were to assist with personal hygiene, but the resident's refusals limited their ability to do so. Another resident, diagnosed with neuromuscular dysfunction of the bladder, spina bifida with hydrocephalus, and morbid obesity, also had a room with a strong urine odor that extended into adjacent areas. This resident, while cognitively intact, required supervision and some assistance with ADLs but often refused staff and housekeeping entry, preferring to manage personal care independently. Staff interviews revealed that the odor had been present for a long time, and the resident's reluctance to allow cleaning or assistance contributed to the problem. The care plan specified assistance with personal hygiene and elimination, but the resident's refusals limited staff intervention, resulting in persistent odors. Additionally, the facility failed to fully investigate and track missing personal items for a resident who reported a missing clothing item for approximately two months. The resident, who was alert and oriented, reported the missing item to housekeeping, but the facility's follow-up was inconsistent. The housekeeping director was initially unaware of the missing item and lacked knowledge of the facility's tracking system and policy for lost items. Although a policy and grievance process existed, it was not consistently followed, and there was no established tracking log in use. The facility's grievance log showed other missing items, some of which were replaced, but the process for investigating and resolving missing items was not systematically implemented.