Failure to Maintain Sanitary and Homelike Environment for Two Residents
Penalty
Summary
Staff failed to maintain a safe, clean, and homelike environment for two residents who shared an adjoining bathroom. Observations revealed that the bathroom doorknobs were missing and inaccessible to the residents, and the bathroom itself was left in unsanitary condition, with soiled towels piled on the floor, brown smears above the tile, and a solid dark substance in the toilet bowl. The wall across from the toilet was covered with brown cardboard instead of tile. Maintenance staff reported that the doorknobs were removed due to residents' behaviors of clogging the toilet and smearing feces, and that the bathroom was locked as a result. One resident had moderate cognitive impairment, was dependent on staff for toileting and transfers, and had a history of urinary and occasional bowel incontinence, as well as diagnoses including hypertension and Alzheimer's disease. The other resident also had moderate cognitive impairment, required partial to moderate assistance with toileting, and had diagnoses including heart failure, pulmonary edema, diabetes, and hypertension. Observations in the second resident's room showed a trash can with a plastic liner containing yellow liquid, which staff confirmed was urine, and reported that the resident frequently urinated in the trash can and defecated in inappropriate places in the room. Housekeeping staff stated that they cleaned the resident's room daily, removed soiled trash liners, and replaced them, but acknowledged that the resident regularly urinated in the trash can. The facility's policy required maintaining a sanitary and comfortable environment, including prompt cleaning and reporting of environmental concerns. The administrator was aware of the unsanitary bathroom conditions and stated that the staff responsible was no longer employed, but expected all staff to follow cleaning policies.