Failure to Maintain Safe and Sanitary Resident Environment
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment for a resident with multiple medical conditions, including congestive heart failure, dementia, and a history of falls. Observations revealed that the resident's mattress was not properly positioned on the bed frame, leaving a portion of the metal frame exposed. Additionally, the bed was unmade, and pillows lacked pillowcases. A plastic cup was found under the bed, and the resident's bathroom contained several used disposable gloves in the sink, a plastic cup, and coffee mugs placed on the toilet. Dirty clothing was left on a shower chair, and briefs were found near the shower, some of which were not covered. Interviews with staff confirmed that the resident was capable of some self-care but often left soiled briefs and gloves in the bathroom. Staff acknowledged their responsibility to check rooms for environmental issues and to dispose of used items immediately to maintain sanitation. However, they were unable to account for the presence of dirty clothing and coffee cups in the bathroom. The staff also noted that the mattress may have been moved by the resident, resulting in the exposed bed frame, and that coffee cups should have been returned to the kitchen after use. Facility policy required regular environmental rounds and immediate disposal of soiled items to prevent contamination. Despite these policies, the observed conditions in the resident's room and bathroom did not meet the standards for cleanliness and safety. The resident, when interviewed, expressed satisfaction with her living conditions and denied noticing any unsanitary items, but further observation revealed improperly stored food items in her room. The facility's failure to adhere to its own policies and maintain a sanitary environment was documented through direct observation and staff interviews.