Failure to Provide Clean Linens and Maintain a Safe, Clean Environment
Penalty
Summary
A deficiency occurred when a resident was left with soiled bed linens for multiple days, despite facility policy requiring a safe, clean, and comfortable environment with clean bed and bath linens. Observations over several days revealed the resident's bed sheets were visibly soiled with blood and other stains, attributed to the resident's weeping and bleeding legs. The resident reported that her sheets were only changed on shower days, and on multiple occasions, she confirmed that her linens had not been changed for at least a week. Staff interviews corroborated that the soiled linens were not changed, even after being made aware of their condition, and clean linens were left in the room but not placed on the bed. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had a medical history including Type 2 Diabetes Mellitus. Despite the resident's ability to communicate her needs and the visible evidence of soiled linens, staff failed to provide timely linen changes. The DON and Administrator both acknowledged that residents should not be left on soiled linens and that linens are expected to be changed at least every other day and as needed, but these expectations were not met in this instance.