Soiled Bed Linens Found on Multiple Made Beds in AACU
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean, safe, and homelike environment by allowing multiple residents to have made beds with visibly soiled linens on the Advanced Alzheimer’s Care Unit (AACU). During observations conducted with the AACU Supervisor, four of seven resident beds were found with dirty linens despite appearing to be made. One resident’s bed had a moderate amount of a brown substance on the top sheet hanging over the side of the bed, which the AACU Supervisor acknowledged. Another resident’s bed, when the top sheet and cover were removed, revealed brown stains on the bottom sheet. A third resident’s bed was made with a bottom sheet, top sheet, and bed cover, but when the top layers were removed, food crumbs were observed on the bottom sheet and a brown substance was present on the pillowcase. A fourth resident’s bed, made with a bottom sheet and bath blanket, was found to have brown stains on the bottom sheet once the blanket was removed. The AACU Supervisor stated that these four beds had soiled linens that had been made without the linens being changed by the night shift. The Administrator later reported that both night and day shift staff denied making the beds and suggested that residents may have made them, and also indicated there was no facility policy for changing linens. The residents involved all had significant cognitive impairments and varying levels of dependence on staff for activities of daily living (ADLs). One resident with Alzheimer’s disease had a severely impaired cognitive status, required staff assistance for bed mobility, bathing, and transfers, and was occasionally incontinent; her care plan noted she would sometimes make her own bed but required one to two staff for ADLs and short, simple instructions. Another resident with vascular dementia had a severely impaired cognitive status, was dependent on staff for toileting, showers, dressing, bed mobility, transfers, and ambulation, and was frequently incontinent; there was no care plan indicating she made her own bed. A third resident with dementia and bipolar disorder required moderate to maximum assistance for ADLs, was frequently incontinent, and had impaired cognition with need for cueing and supervision, with no care plan indicating she made her own bed. The fourth resident, with Alzheimer’s disease and severely impaired cognition, required staff assistance for ADLs, was frequently incontinent, and also had no care plan indicating he made his own bed.
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