Failure to Provide Consistent Bathing and ADL Care
Penalty
Summary
The facility failed to provide necessary activities of daily living (ADL) care and services, specifically bathing, for two of three sampled residents. One resident, who had no cognitive impairment and was dependent on staff for bathing and transfers, reported only receiving bed baths and stated that showers were missed, particularly on weekends when the designated shower aide was not present. Documentation confirmed that this resident received only sporadic bed baths and showers over a four-week period, with gaps in care and incomplete records. Staff interviews revealed that the shower aide worked only weekdays, and floor staff were expected to provide showers on weekends, but it was unclear if this occurred. Paper documentation of bathing was inconsistent and not always entered into the electronic record. Another resident, with moderate cognitive impairment and dependent on staff for bathing, also experienced missed showers, with records showing only one shower during a two-week period after admission. Staff were unable to consistently locate documentation of bathing for this resident, and additional records were only found after further searching. The facility's policy was for residents to receive one to two showers or baths per week according to their preference, but this was not consistently provided or documented for the residents reviewed.