Failure to Maintain Clean and Safe Resident Environment After Enteral Feeding Spill
Penalty
Summary
Facility staff failed to maintain a safe, clean, and homelike environment for a resident who was dependent on staff for most activities of daily living and received the majority of nutrition through a gastrostomy tube. The resident, who had diagnoses including dementia and dysphagia, was found with spilled Glucerna formula on their fitted bed sheet, bed sheet, bedrail padding, and the floor. Staff present at the time acknowledged that the enteral feeding formula had leaked and that the environment was not clean or sanitary. Housekeeping had not been called to clean the floor, and the bedrail padding had not been replaced or cleaned at the time of observation. The facility's policy and procedure required staff to provide a safe, clean, and comfortable environment and to pay close attention to cleanliness and order. Despite this, staff did not promptly address the spill or ensure the resident's environment was sanitary. The Director of Nursing confirmed that the situation was unacceptable and that any staff member could have assisted in cleaning the environment and bedside padding. This failure resulted in an unclean environment and accident hazard for the resident, other residents, and facility staff.