Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor a resident's preference for a shower, which was a violation of the resident's right to self-determination. Resident 273, who was admitted with conditions including urinary retention, dysphagia, and a urinary tract infection, expressed a desire for showers instead of bed baths. Despite having the cognitive ability to make decisions and requiring only moderate assistance with personal hygiene, the resident's request for showers was not fulfilled. The facility's shower schedule indicated that the resident was to receive showers on Mondays and Thursdays, but the resident reported not having received a shower since admission. Interviews with staff revealed that there was no valid reason for denying the resident's request for a shower. A CNA confirmed that the resident had approval from the Physical Therapist to have showers, and the Director of Rehab stated that the resident required minimal assistance with transfers and was capable of standing and walking. The facility's policy stated that residents should be offered showers at least once a week and according to their requests, and the resident rights policy emphasized the importance of honoring residents' choices regarding personal care. The failure to provide the requested showers had the potential to affect the resident's psychosocial well-being, as noted by the Director of Staff Development.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25 Resident 273 was given a shower by assigned CNA. Social Services Director followed up with resident 273 in regards to receiving a shower. Resident 273 expressed no further adverse reaction or negative outcome from not receiving a shower. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/25 Social Services Director and Social Services Assistant conducted resident interviews to ensure residents are receiving a shower. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25 the Director of Staff Development (DSD) in-serviced Nursing Staff, including but not limited to License Vocational Nurse, Registered Nurses, Certified Nursing Assistants (CNA), and Restorative Nursing Assistants (RNA) on the facilities policy and procedure titled, "Showering a Resident" with emphasis on ensuring residents are offered a shower at a minimum of once weekly and given per resident request. On 3/11/25, the DSD in-serviced Nursing Staff, including but not limited to LVNs, RNs, CNAs, and RNAs on the facilities policy and procedure titled, "Resident Rights," with emphasis on residents being allowed to choose activities, schedules and health care that are consistent with their interest, assessments and plan of care including personal care needs such as bathing methods and grooming styles. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/25 Social Services Director and Social Services Assistant conducted resident interviews to ensure residents are receiving a shower. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25 the Director of Staff Development (DSD) in-serviced Nursing Staff, including but not limited to LVNs, RNs, CNAs, and RNAs on the facilities policy and procedure titled, "Showering a Resident" with emphasis on ensuring residents are offered a shower at a minimum of once weekly and given per resident request. On 3/11/25, the DSD in-serviced Nursing Staff, including but not limited to LVNs, RNs, CNAs, and RNAs on the facilities policy and procedure titled, "Resident Rights," with emphasis on residents being allowed to choose activities, schedules and health care that are consistent with their interest, assessments and plan of care including personal care needs such as bathing methods and grooming styles. Department Managers will conduct rounds daily for five days weekly for two weeks and monthly thereafter to ensure residents are receiving a shower as scheduled. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will review the Department Manager rounds and will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for showers given to residents for three months or until compliance is met.