Failure to Maintain Sanitary and Homelike Resident Environments
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment in resident rooms and with bedside urinals for two residents. For one resident with chronic obstructive pulmonary disease, cachexia, and major depressive disorder, observations revealed a room with used gloves in the garbage, soiled and sticky floors, dried food on the floor, and a fly present. The resident’s bathroom had a strong urine odor and personal medical equipment, including two specialized bedside urinals, which were visibly soiled with a thick layer of dried sediment. Staff reported cleaning these urinals only with water, as the resident disliked the smell of cleaning chemicals, and no disinfecting solutions were used. The resident’s care plan did not document any preferences or interventions regarding cleaning solutions or the maintenance of personal equipment. Staff interviews confirmed that the cleaning process for the specialized urinals did not meet infection control expectations, and the infection preventionist was unaware of the specialized urinal or any plan for its cleaning, disinfecting, or storage. Housekeeping staff also reported using only hot water to clean the room due to the resident’s aversion to cleaning solution odors and had not attempted to use odorless or fragrance-free products. The daily cleaning routine was further complicated by the presence of numerous personal belongings in resident rooms, making it difficult to clean all surfaces effectively. For another resident with diabetes, circulatory complications, and a foot ulcer, observations found the room cluttered with personal belongings, food wrappers, empty soda bottles containing chewing tobacco and spit, and a fly present. The resident stated that their room was cleaned only two to three times per week and that housekeeping did not remove garbage unless it was placed in the trash can. The resident also reported that the counter and sink had not been cleared or wiped down in a long time. These findings indicate that facility policy for cleaning resident rooms and personal equipment was not followed for both residents.