Failure to Maintain Clean Bed Environment for Resident With Wound Infection
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment for a resident with dementia, ADL self-care deficits, and a sacral wound infection being treated with Bactrim DS. The resident’s care plan documented substantial/maximal assistance with toileting hygiene and an active infection of the sacral wound. During an observation, surveyors noted a brownish dried substance identified by the Administrator as feces smeared on the resident’s bed frame. The resident was not interviewable. The facility’s policy on Standard Precautions stated that environmental surfaces, including bedrails and bedside equipment, are to be appropriately cleaned. Interviews with staff confirmed that the substance on the bed frame was unsanitary and that CNAs and nursing staff were responsible for ensuring residents’ beds and environments were clean and free of bodily fluids and fecal matter. The Administrator, LVN, CNA, and interim DON each acknowledged that nursing staff were primarily responsible for cleaning body fluids from bed frames before housekeeping sanitized the area, and all recognized the risk of infection related to exposure to fecal matter. Staff also reported having been inserviced on infection control, including keeping residents’ beds clean, yet the fecal matter on the bed frame had not been identified or cleaned prior to the surveyor’s observation.
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