Failure to Maintain Safe and Clean Environment for Resident with Incontinence
Penalty
Summary
A deficiency was identified when a resident's right to a safe, clean, comfortable, and homelike environment was not honored. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, muscle weakness, major depressive disorder, vascular dementia, type II diabetes mellitus, and paranoid schizophrenia, was observed in a room with significant sanitation issues. The resident was always incontinent of bowel and bladder, required maximum assistance with activities of daily living except eating, and needed frequent checks and assistance with toileting. Despite these needs, the resident was found sitting in his wheelchair, naked from the waist down, with wet pants on the floor, and a pool of urine on the floor. The bathroom had smeared dried feces extending from the toilet to the sink, and the room had a strong odor of urine and feces with sticky floor tiles. Interviews revealed that the housekeeper assigned to the resident's hall did not start work until later in the morning, and although the floor was mopped twice daily, the sticky substance and feces persisted. The CNA assigned to the resident admitted to not performing rounds or entering the room as required, mistakenly believing the resident could toilet independently. The CNA also acknowledged the resident deserved a clean room and recognized the embarrassment caused by the unsanitary conditions. The LVN assigned to the resident was unaware if rounds had been completed and did not check on the resident during the morning medication pass, stating the resident would not use the call light to request assistance. Facility leadership, including the DON and Administrator, confirmed that the resident required frequent checks and that the room's condition was unacceptable. The DON acknowledged the risk of infection and health issues due to the presence of urine and feces on the floor and accepted accountability for the nursing care provided. Facility policies and job descriptions reviewed indicated a requirement for maintaining cleanliness and a safe environment, but these standards were not met in this instance.