Failure to Maintain Clean Linens and Remove Soiled Items for Resident with Draining Wound
Penalty
Summary
A deficiency was identified when a resident with a history of coronary artery disease, heart failure, diabetes mellitus, and anemia, who was alert and oriented, was not provided with a clean and comfortable environment as required. The resident had a diabetic and arterial ulcer on the left lower leg, which was draining and required regular dressing changes. Observations revealed that the resident's bed linens were soiled with dried stains of reddish, brown, and yellow substances, and the resident's feet were resting on these stained linens. The bandage on the resident's leg was also soiled, and two sets of soiled protective boots were left piled on top of the resident's drawers for approximately two weeks. Interviews with staff indicated that the treatment nurse had repeatedly found the resident's linens soiled over the past two weeks and had informed other staff, but the situation did not improve. The nurse reported instances where the resident's leg dressing was stuck to the soiled linens and required saline to remove it. The resident confirmed that he disliked having dirty sheets, had informed staff, and noted that the night shift often did not change his linens, leaving him to wait for the day shift. The resident also stated that the soiled boots remained in his room until the surveyor's intervention. Additional interviews with CNAs and nurses revealed inconsistent awareness and action regarding the resident's needs. Some staff were unaware of the frequency of the wound drainage or the discomfort caused by the dressing sticking to the linens. Staff acknowledged that soiled linens and dressings should be changed, but the practice was not consistently followed. Facility leadership confirmed that maintaining resident dignity and cleanliness was expected, and that soiled items should be removed from resident rooms.