Failure to Provide Clean Bed Linens and Maintain Resident Hygiene
Penalty
Summary
A resident with multiple sclerosis, malnutrition, and a self-care deficit related to post-surgical status required assistance with activities of daily living (ADLs), including dressing, grooming, bathing, mobility, and incontinence care. The resident remained in bed for meals due to mobility concerns and expressed frustration about not receiving a bath or a change of bed linens since admission. Observations revealed that the resident's bed linens were visibly soiled with crumbs and coffee stains, and the bottom sheet was not properly fitted. Despite the resident receiving a shower and hair wash, the same soiled linens were placed back on the bed without being changed. Interviews with staff confirmed that linens should be changed on bath days and as needed if soiled, but this was not done for the resident in question. The facility's policy on ADLs emphasized person-centered care and quality of life but did not include specific guidance on maintaining a clean, hygienic environment or the provision of fresh bath and bed linens. Additionally, when requested, the facility was unable to provide a policy specifically addressing the change of bed linens.