Failure to Provide Clean Bed Linens and Maintain Resident Dignity
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living due to conditions including diabetes with nephropathy and incontinence, was found lying in bed with unclean linens. During observation and interview, the resident was noted to have unbrushed hair, clothing with food crumbs, and sheets with a urine odor and multiple large brown dried stains. The resident reported not having been showered in eight days and expressed feeling dirty and uncomfortable. Staff interviews revealed that certified nurse aides (CNAs) were responsible for changing bed linens, but due to miscommunication and staff shortages, the resident's sheets had not been changed as needed. The CNAs were unaware of the stained sheets until it was brought to their attention during the survey. Further interviews with staff, including a licensed vocational nurse (LVN) and the Director of Clinical Operation, confirmed that facility policy required sheets to be changed on shower days and as needed if soiled, and that stained or worn sheets should be discarded. The failure to provide clean bed linens in good condition resulted in the resident experiencing an uncomfortable and unclean environment, contrary to facility policy and the resident's right to a safe, clean, and homelike setting.