Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to honor the resident representative's request to ensure that a resident received a shower on the scheduled shower days. The resident, who was admitted to the facility with severe cognitive impairment and was dependent on all care needs, had a shower schedule set for every Monday and Thursday during the 3 PM - 11 PM shift. However, documentation from the CNA task list showed that the resident received only four bed baths and three tub baths on the scheduled shower days between February 27 and March 24. An observation in the resident's room revealed a note written by the resident's sister, requesting that the resident receive a shower on her shower days. Interviews with staff confirmed the lack of shower documentation and revealed that the facility did not have a tub, which contributed to the deficiency.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. F561 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #71 was provided with a shower as scheduled. Staff C was re-educated to provide and document showers provided on residents' shower days and any additional days that the residents receive a shower. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Facility audit conducted to ensure residents' showers are completed on scheduled shower days and documented appropriately. Other residents found to be affected were corrected. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Certified Nursing Assistants (C.N.As) have been re-educated regarding Resident Rights/Right of Choices as related to receiving shower on the scheduled shower days. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Random observation will be conducted three times per week / three months to ensure compliance. Director of Nursing/Designee will conduct weekly shower audits times four weeks and will report the findings of the audits to the QAA&C monthly times three months or until substantial compliance is met.