Failure to Provide Clean Linens and Honor Resident Choice for Mattress Cover
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to a safe, clean, comfortable, and homelike environment, specifically regarding bed linens and use of pressure reduction mattresses. One resident with Stage 3 and Stage 4 sacral pressure ulcers and a Stage 2 buttocks pressure ulcer had a physician’s order for a pressure reduction mattress and was always incontinent of bowel and bladder. Manufacturer guidelines for the pressure mattress allowed for a thin cotton sheet over the top cover. Multiple observations on separate days showed this resident lying with skin in direct contact with the mattress surface and no sheet in place. The resident reported that she had asked staff for a cover sheet, but her request was not honored. The CNA Supervisor stated that while the facility’s practice was not to use a cover sheet on pressure reduction mattresses, a sheet should be provided if requested as part of resident rights. The DON confirmed that the facility’s practice was not to use a cover sheet and that residents were not given a choice, although they should have been. The deficiency also includes failure to maintain clean, dry bed linens for another resident who was always incontinent of bowel and bladder. This resident reported that her bed linens were wet and soiled, which was confirmed by observation. On the following day, the resident stated that her linens were still soiled and had not been changed, and observation revealed dried brown and yellow stains on the bed linens. The CNA Supervisor indicated CNAs were expected to check resident rooms every two hours for needs or assistance and that CNAs were responsible for checking and changing soiled bed linens. A CNA stated that linens should be changed when requested by a resident or when wet or soiled. Both the DON and CNA Supervisor acknowledged that this resident’s linens should not have remained soiled and should have been changed in a timely manner.
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