Failure to Provide Scheduled Showers per Resident Representative's Request
Penalty
Summary
The facility failed to honor a resident representative's request to ensure that a resident received showers on their scheduled shower days. The resident, who was dependent for all care needs as indicated by a Minimum Data Set (MDS) assessment score of 3, had a posted note from her sister on the bulletin board requesting that she receive showers on her scheduled days. The resident's care plan included showers every Monday and Thursday during the 3 PM-11 PM shift. Record review showed that, instead of showers, the resident received four bed baths and three tub baths on the scheduled shower days. Staff interviews confirmed that a bed bath was provided instead of a shower, and the Director of Nursing verified the lack of shower documentation on the CNA task list. It was also confirmed that the facility does not have a tub, further indicating that the resident did not receive showers as scheduled.
Plan Of Correction
N 181 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.