Failure to Maintain Clean, Odor-Free Environment Due to Inadequate Response to Incontinence and Care Refusals
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment free of institutional odors for a resident who was frequently incontinent of urine and required substantial staff assistance for toileting and hygiene. The resident was cognitively intact, able to verbalize needs, and often refused care such as brief changes, bathing, and hygiene multiple times per week. The care plan instructed staff to check and change the resident every 90-120 minutes and as needed, and to notify the nurse and reapproach if care was refused. However, there was no documentation showing how strong odors resulting from care refusals were minimized or addressed. Multiple observations over several days noted a strong urine odor emanating from the resident's room into the hallway. Staff interviews confirmed that the room had a persistent urine odor, the mattress had been saturated and replaced, and a puddle of urine was found under the bed. Housekeeping deep cleaned beds on shower days, but it was unclear if cleaning frequency was increased in response to care refusals. The DON acknowledged the odor issue and the recent disposal of the soiled mattress, but no odor-eliminating interventions had been care planned.