Failure to Provide Adequate Linens and Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for two of six sampled residents by not ensuring the availability of sufficient linens, incontinent pads, towels, and blankets. Multiple observations revealed that linen storage stations and carts were repeatedly found without essential items such as blankets, incontinent pads, towels, and sheets at various times of the day and night. Staff interviews confirmed that linen shortages occurred, particularly at the start of shifts and during nighttime hours, resulting in residents having to wait for clean linens to be delivered from the laundry department. One resident, with diagnoses including gait disturbance, spondylosis, and COPD, required substantial to maximum assistance with activities of daily living (ADLs) and reported that only their diaper was changed during nighttime care, not the sheets or blankets. The resident expressed a desire for fresh and clean blankets. Another resident, with hemiplegia, metabolic encephalopathy, and diabetes, was dependent on staff for ADLs and reported that nurses ran out of sheets and towels during the night, leading to situations where only the diaper was changed and not the sheets, resulting in discomfort from sweaty sheets. Staff interviews corroborated the residents' accounts, with laundry and nursing staff acknowledging the importance of having adequate linens available for resident care and comfort. The facility's policies required the provision and maintenance of clean bed and bath linens, but the observed and reported shortages indicated a failure to meet these standards, directly impacting the residents' environment and care.