Failure to Maintain Clean, Odor-Free, and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident's room was found to be unclean and had a persistent strong urine odor. The resident, a male with hypertensive heart disease, paraplegia, and spinal stenosis, required total assistance with toileting hygiene and was occasionally incontinent of urine. Observations revealed that the resident kept two urinals hanging on a trashcan beside his bed, both containing urine, and the floor near the bed and trashcan was wet, sticky, and had flies present. The resident reported that staff did not empty his urinals frequently enough, leading him to sometimes empty them into the trashcan himself, which contributed to the odor and uncleanliness in the room. Interviews with staff confirmed that urinals should be emptied at least every two hours, but this was not consistently done. A CNA noted that the urinal was overflowing and urine had spilled onto the floor, which she attempted to clean. Housekeeping staff reported ongoing issues with urine odor in the room, attributed to the resident's use of urinals and occasional incontinence, and stated that while the room was cleaned daily, there were no special cleaners available to address urine odors. The housekeeping supervisor and other staff acknowledged the persistent odor and the challenges in maintaining cleanliness, despite daily cleaning and attempts at deep cleaning. Facility leadership, including the Assistant Director of Clinical Operations and the Administrator, recognized that staff should have been checking and emptying the urinals more frequently. They also noted that the resident did not like staff entering his room at night, which may have contributed to the issue. The facility's policy emphasized the importance of a clean, sanitary, and homelike environment, but the ongoing presence of urine odor and unclean conditions in the resident's room demonstrated a failure to meet these standards.