Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
Facility staff failed to maintain a clean, odor-free, and homelike environment for a resident with severe cognitive impairment and total dependence on staff for daily living activities. Observations revealed a strong urine odor around the resident's bed and room entrance, as well as a dirty, wet, and smelly gray fall mat at the right side of the bed. The fall mat was noted to have foot prints, scuff marks, and a drying sticky wet mark. A Certified Nursing Assistant (CNA) acknowledged the strong urine odor and the unclean condition of the fall mat, attributing the situation to not having had a chance to change the resident's incontinence brief due to being occupied with other residents. The resident involved had multiple medical diagnoses, including diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, gastrostomy, hypertension, and dysphagia. The Minimum Data Set assessment indicated the resident was totally dependent on staff for bed mobility, dressing, toileting, bathing, and personal hygiene. The facility's policy required a safe, clean, comfortable, and homelike environment with pleasant, neutral scents, but these standards were not met in this instance.