Failure to Provide Appropriate Linens and Maintain Shower Equipment to Honor Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences regarding bed linens. One resident with morbid obesity, knee dislocation, and impaired lower extremity function was observed twice on the same day lying directly on a bariatric mattress without a fitted sheet. The resident reported that the facility frequently ran out of fitted sheets, gowns, and towels, and stated she did not refuse linens but that they were not available. An LPN confirmed the resident was lying on a bare mattress. Inspection of the south hall linen area, the north linen closet, and the second floor revealed no bariatric fitted sheets available for staff use. In the laundry area, only two bariatric fitted sheets were eventually located after searching, and the DON confirmed there were no bariatric fitted sheets in the residential areas. The deficiency also includes failure to honor another resident’s stated bathing preference due to lack of functioning equipment. This resident, who had cerebral infarction, cellulitis, type 2 diabetes, morbid obesity, and significant upper and lower extremity impairments, was cognitively intact and care planned to have ADL assistance with honoring choices and preferences whenever possible. Facility documentation showed it was very important to this resident to choose between types of bathing, and he specifically preferred showers. However, shower records over a nearly three‑month period showed he received only bed baths. The resident reported he had not received a shower for two and a half to three months and was told by staff that the shower bed he required was broken. Observation confirmed the shower bed was missing pins that held the frame together, and staff, including an LPN and a CNA, stated the shower bed had been nonfunctional for weeks to a couple of months and was the only shower bed available, preventing the resident from receiving showers.
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