Failure to Provide Adequate CNA Staffing for Resident Hygiene Needs
Penalty
Summary
The facility failed to provide a sufficient number of Certified Nurse Aides (CNAs) and Shower Aides to meet the needs of residents as outlined in their care plans. Specifically, a resident with metabolic encephalopathy and morbid obesity, who required substantial to maximal assistance for bathing, did not receive scheduled showers on multiple occasions. The resident reported missed showers due to short staffing, and this was corroborated by interviews with staff and review of the electronic shower log and whirlpool schedule. On several days, the shower room was not used during the day shift, and CNAs assigned to the shower room were pulled to work on the floor, leaving no one available to provide showers to residents who required two-person assistance. Staff interviews confirmed that when only one shower aide was present, residents needing two-person assistance did not receive showers because other aides were unavailable to help. Multiple CNAs stated they were unable to provide showers due to being reassigned to floor duties or lacking sufficient help. The DON and Administrator acknowledged that there were missed and undocumented scheduled showers, and observations confirmed the shower room was unused on certain days. These actions and inactions resulted in the facility's failure to ensure residents received necessary hygiene care in accordance with their care plans.