Failure to Maintain Cleanliness and Wound Dressings for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment and to provide necessary ADL support for a resident with extensive physical impairments. The resident was admitted with multiple diagnoses including right below-knee amputation, chronic venous hypertension with ulcer and inflammation of the left lower extremity, cellulitis, obesity, edema, anemia, hypothyroidism, bilateral blindness, hypertension, peripheral vascular disease, gastro-esophageal reflux, absence of right and left fingers, muscle weakness, Type II diabetes, and osteomyelitis. The resident’s care plan, last revised on 01/16/26, documented that the resident required staff assistance with ADLs due to right below-knee amputation, diabetic neuropathy, complete bilateral blindness, and amputation of all fingers except bilateral thumbs. Care plan interventions included assisting with bathing, clothing choices, dressing, and daily wound monitoring and care, including checking for signs of infection, drainage, bleeding, skin breakdown, impaired circulation, documenting drainage, and rewrapping the stump as ordered and as needed. On 02/24/26 at 11:13 A.M., observation revealed the resident had bilateral open wounds on the hand stumps and uncountable red smear marks on the gown and bedding. At 11:14 A.M., the resident stated that the bilateral hand stumps were supposed to be covered with dressings but were not, and the resident was unaware of the red smear marks on the gown and bedding and expressed a desire to be cleaned up, stating they were upset about being in a soiled gown and bedding. At 1:05 P.M., the Assistant Director of Nursing confirmed that the resident’s gown and bedding were soiled with red marks. Review of the facility’s undated ADL policy indicated that residents unable to carry out ADLs would receive necessary services to maintain grooming and personal hygiene, which was not followed in this instance. This failure affected one resident reviewed for ADLs and was investigated under Complaint Number 2645121.
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