Failure to Provide Clean Bed Linens for Resident
Penalty
Summary
A deficiency was identified in one resident room on the 200 hall where clean bed linens were not provided for an extended period. The resident in the affected room reported that his sheets had not been changed in a month and demonstrated to the surveyor that he had placed his initials on the underside of the sheet to track changes. Observations over three consecutive days confirmed the presence of the resident's initials, indicating the sheets had not been changed during that time. Certified Nurse Assistants (CNAs) working on the 200 hall confirmed that bed linens were not being changed as often as required, stating that linens should be changed on bath days or as needed, but that workload prevented them from completing this task. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that CNAs were responsible for changing linens and agreed that the resident's sheets had not been changed as required, with the DON stating that the situation was unacceptable.