Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
A facility failed to provide a safe, clean, and homelike environment for a resident who was dependent on staff for all activities of daily living due to severe cognitive impairment and functional quadriplegia. The resident's linens had not been changed for 8 days, and observations revealed dried fecal matter and food crumbs on the bedding. The resident reported having requested multiple CNAs to change his sheets, but staff did not return to complete the task after stating they needed assistance. The resident received bed baths on scheduled days, during which linen changes were supposed to occur, but this was not consistently done. Interviews with the resident's family member confirmed ongoing complaints about unchanged linens and unmet care needs. Staff interviews revealed that CNAs were responsible for changing linens, typically on shower or bed bath days, and were expected to document any refusals of care. However, there was a lack of follow-through, and the linen remained soiled despite the resident's requests and scheduled care routines. Observations on consecutive days confirmed that the condition of the linens did not improve. Nursing and administrative staff, including the interim DON and the administrator, acknowledged that linens should be changed on shower days and as needed, and that failure to do so could result in dignity issues and potential health concerns. The facility's resident rights policy emphasized the right to live in safe, decent, and clean conditions, which was not upheld in this instance.