Failure to Provide Timely Linen Changes and Bathing for a Medically Complex Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment and to provide timely linen changes and bathing for a resident with multiple serious medical conditions. The resident was admitted with COVID-19, sepsis due to E. coli, a liver abscess, Klebsiella pneumonia, Diabetes Mellitus Type II, and other comorbidities, and had a care plan indicating bacteremia due to Klebsiella with IV antibiotics. The admission progress record documented that the resident was alert, oriented, and able to make needs known. On multiple observations from March 3 through March 6, the resident consistently reported that their bedding and linens had not been changed since admission. Surveyors observed stains, appearing to be food residue, in the area where the resident was seated on March 5, and on March 6 the same stained linens remained on the bed, confirming that the bedding had not been changed. The resident also reported having received a shower on March 4, but there was no documentation of this in the record. Review of the shower record showed only one documented shower since admission, on February 27. CNAs reported that usual practice was to change bed linens three times per week, particularly after showers or when linens were soiled, and that residents were expected to receive showers twice weekly. The RN and DON confirmed that bedding was to be changed on scheduled shower days or as needed, and that residents were scheduled for showers twice weekly or upon request. The DON stated the resident had three shower episodes since admission, but this was not supported by the shower record, which showed only one shower. The facility did not maintain a bedding change log. The facility’s Quality of Life policy stated that bathing would be offered twice weekly unless otherwise requested and that daily care, including personal hygiene, would be provided and documented according to assessed needs.
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