Failure to Safeguard and Return Residents’ Personal Clothing After Laundering
Penalty
Summary
Facility staff failed to protect and maintain residents' personal clothing and ensure items were returned after laundering for three residents. One resident with a history of stroke, hemiparesis, and aphasia, and a BIMS score indicating moderately impaired decision-making, reported that clothing sent to the laundry over a week earlier had not been returned. He repeatedly expressed distress about having to wear the same clothing because his laundered items were missing and was observed on multiple occasions asking staff for assistance in retrieving his clothing from the laundry. During an interview in his room, he again raised the issue of his missing clothing in the presence of the ADON. Another resident with stroke, diabetes, and seizure disorder, and a BIMS score indicating intact cognition, stated that all of his clothing was missing after being sent out for cleaning and that staff continued to bring other residents' clothing in his size instead of returning his own items. He pointed out donated clothing on his bed and reported watching other residents to see who might be wearing his clothing. A third resident with stroke, atrial fibrillation, and dementia, but intact decision-making per BIMS, stated that all his coats were missing and that he was afraid to remove the coat he was wearing for fear it would be lost. He was observed wearing the same coat and later returning from a shower, and during an interview with the ADON he again reported his missing clothing. These incidents demonstrate that staff did not adequately safeguard or track these residents' personal clothing during and after laundering.
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