Persistent Urine Odor and Unsanitary Room Environment for a Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to provide a safe, sanitary, comfortable, and homelike environment for one resident. The resident was admitted with acute kidney failure, chronic kidney disease, muscle weakness, and a need for assistance with personal care, and had a care plan indicating incontinence related to impaired mobility and behaviors, with use of briefs. The MDS showed the resident had a BIMS score of 15, sometimes refused care 1–3 days per week, and required substantial assistance to toilet. On the survey date, surveyors noted a strong urine odor on the second-floor hallway upon exiting the elevator, which intensified near and inside the resident’s room. Inside the room, the bed was unmade, with a mattress protector and sheet that were faded yellowish/brown, and there was a strong ammonia-like urine odor; the resident stated he could not smell the odor. Later the same day, surveyors again noted a persistent urine odor in the hallway even with the resident’s door closed, and upon opening the door, the urine odor was so strong the surveyor could only remain in the room for a few minutes, despite the bed having been made. A housekeeper reported working the 12:00 pm–8:00 pm shift and cleaning the resident’s room about three times a day, with the 6:00 am–2:00 pm shift also cleaning the room once daily. The housekeeper stated the resident’s mattress had been changed in an attempt to address the odor, but this did not help, and that staff frequently complained about the smell. The Maintenance Director acknowledged the room had smelled that way “for a while” and that cleaning had not resolved the issue; he stated the room floors could not be stripped and that they continued to try to clean the room. The Administrator reported ongoing issues with the resident not getting out of bed to use the toilet and refusing to use the briefs provided, contributing to the persistent urine odor and unsanitary room conditions.
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