Failure to Provide Clean Bed Linens for Resident
Penalty
Summary
A deficiency was identified when a resident's bed linens were observed to be unclean, with numerous brown stains and a crusty yellow substance present on the top sheet. The resident, a female with a history of dementia and schizophrenia but no cognitive impairment per her most recent MDS, was found lying in the soiled bed linens on multiple occasions. The resident reported that her sheets were typically changed on her scheduled shower days, which were Monday, Wednesday, and Friday, but stated that her sheets had not been changed after her most recent shower. She expressed discomfort and dissatisfaction with the condition of her bedding. Interviews with facility staff revealed inconsistencies and lapses in the process for changing bed linens. Nursing assistants confirmed that linens should be changed on shower days and as needed if visibly soiled, but one NA noted that clean linens from the laundry often arrived stained and that she had not reported this issue. The Housekeeping Supervisor stated that laundry staff were trained to remove stained or torn linens, but also indicated that CNAs were responsible for changing linens if they became soiled. The CNA Supervisor and DON both stated that linens should be changed on shower days and as needed, but there was no system in place to monitor the condition of bed linens, and it was unclear if the resident had refused linen changes. The facility's policy required clean bed and bath linens in good condition to maintain a homelike environment. Despite this, the lack of a monitoring system and failure to ensure linens were changed as required resulted in the resident remaining in soiled bedding, which was directly observed and confirmed by both the resident and staff interviews.