Failure to Timely Change Soiled Bedding and Maintain Shower Room in Good Repair
Penalty
Summary
The facility failed to ensure that visibly soiled bedding was changed in a timely manner for a resident with quadriplegia, tracheostomy status, ventilator dependence, and a gastrostomy tube. Observation revealed a dried, brownish stain approximately 2.5 inches in size on the resident's sheet near the right wrist. The resident was dependent on staff for all activities of daily living and had intact cognition. A registered nurse verified the stain and believed it was blood from a small scabbed area on the resident's right arm, possibly related to a recent blood draw. The Director of Nursing confirmed that linens should be changed when visibly soiled and provided lab results indicating a blood draw had occurred the previous day. Additionally, the facility failed to maintain the south wing shower room in good repair. Observation showed a basketball-sized hole with broken tiles in the lower part of the wall between the shower and bathroom, under the hand sanitizer. A certified nursing assistant confirmed the damage but was unsure how long it had been present. This issue had the potential to affect 35 residents who used the south wing shower room.