Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for a resident, as evidenced by soiled linen being placed on the floor and the presence of a brown smeared substance on the wall above the linen. Additionally, dried brown substances and yellow liquid stains were observed on the floor next to the resident's bed. These conditions were documented through a photo and video provided by an anonymous employee, which showed the state of the room during the overnight shift. At the time of the surveyor's observation, the room was found to be clean, but the earlier evidence indicated a lapse in maintaining cleanliness and proper handling of soiled materials. The resident involved had a complex medical history, including colostomy status, hepatic encephalopathy, congestive heart failure, and end-stage renal disease. The resident was cognitively intact and had a care plan addressing behavioral issues related to the removal of his ostomy bag. Staff interviews confirmed that the resident had a pattern of removing his colostomy bag, which sometimes resulted in bodily fluids contaminating linens and potentially the environment. Despite this known behavior, staff did not consistently follow protocols for handling soiled linen, as soiled items were left on the floor rather than being immediately bagged and removed according to facility policy. Multiple staff members, including CNAs, LVNs, the ADON, and the DON, acknowledged that soiled linen should not be left on the floor and described the correct procedures for handling contaminated materials. However, there was a lack of clarity regarding who was responsible for the incident, and communication breakdowns were evident, as the DON and other leadership were not made aware of the situation until after the fact. The facility's policy required all soiled laundry to be handled as potentially contaminated, bagged at the location of use, and not sorted or rinsed in resident rooms, but these procedures were not followed in this instance.