Failure to Provide Scheduled Showers and Document Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically personal hygiene and scheduled showers, for three residents who were dependent on staff for these tasks. Documentation showed that one resident missed 8 out of 13 scheduled showers, another missed 8 out of 13, and a third missed 4 out of 14 scheduled showers within a one-month period. All three residents were severely cognitively impaired, as indicated by their BIMS scores, and required total staff assistance for bathing according to their care plans. None of the care plans documented any behaviors of refusal related to showers or other care. Record reviews confirmed that the missed showers were not documented as refusals or rescheduled, and there was no evidence in the electronic health records or care plans to suggest that the residents declined care. Interviews with staff revealed that if a CNA was unable to provide a scheduled shower, the expectation was to communicate this to the nurse and document it, but this was not consistently done. The DON was unaware that residents were not receiving scheduled showers and stated that documentation was only available in the electronic health record, with no additional records to support that showers were provided or refused. Facility policy required that the date, time, and staff involved in showers or tub baths be recorded in the resident's ADL record or medical record. However, the lack of documentation for the missed showers indicated that the facility did not follow its own policy or ensure that dependent residents received the necessary care for personal hygiene as scheduled.