Failure to Provide Clean Footwear for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with dementia and an indwelling catheter, who was dependent on staff for activities of daily living (ADL) care, was not provided with clean footwear over multiple days. Observations revealed the resident wearing the same yellow socks with purple stripes that were saturated with a liquid substance and stained, from one day to the next. The resident was also observed with wet pajama pants and visible wet footprints leading from his room, indicating prolonged exposure to soiled clothing and footwear. Documentation showed the resident required substantial to maximum assistance for toileting and personal hygiene, and his care plan included ensuring comfortable and non-slippery shoes. Interviews with nursing assistants and other staff revealed inconsistencies in the changing of the resident's socks, with one nursing assistant stating she applied the socks and removed them two days later, while another reported changing the socks but could not recall the details. The unit manager and assistant director of nursing were unaware that the resident had worn the same socks for multiple days, despite instructions for staff to replace socks as needed. These findings demonstrate a failure to provide clean footwear as required for a resident dependent on staff for ADL care.