Failure to Provide Clean, Dry Bed Linens for Incontinent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean and comfortable environment by not ensuring timely changing of urine-soaked bed linens for one resident. The resident was an adult male with diagnoses including metastatic intestinal cancer, a left kidney mass with a drainage tube, and acute kidney failure. His admission MDS showed a BIMS score of 14, indicating intact cognition, and assessments documented that he was dependent on staff for toileting hygiene, occasionally incontinent of urine, and on a diuretic. His care plan reflected an ADL self-care deficit related to functional decline and bowel and bladder incontinence. On the survey date at 11:09 AM, the resident was observed lying in bed on a draw sheet saturated with dried urine, evidenced by brown discoloration. The resident reported that his bedding had not been changed since the previous evening, that no one had checked on him that morning, and that he had not realized the bedding was wet and therefore had not notified staff. At 11:14 AM, the assigned CNA stated she had not yet checked on the resident because she had been busy with other residents and was unaware he was incontinent of urine, though she did not feel overworked and noted there were other CNAs on the hall. At 11:19 AM, the ADON stated there was no reason the resident should have been left on dirty linen and that either night shift staff or the day CNA should have identified and changed the soiled bedding during their rounds. The ADON stated the expectation that CNAs and nurses round on all residents at the beginning of their shift to assess needs and acknowledged that lying in urine-soaked linen could result in skin breakdown or irritation. Observation of the resident’s peri area and buttocks at 11:25 AM showed no skin breakdown or excoriation, with some redness from lying on his back. Interviews with other residents on the hall between 11:35 AM and 12:00 PM revealed no complaints about dirty linens and indicated staff checked on them regularly. Review of the facility’s Activities of Daily Living policy did not specifically address linen changes, though it addressed provision of care and services for bathing, dressing, grooming, oral care, and toileting.
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