Failure to Consistently Offer and Document Bathing Assistance for Resident Requiring ADL Support
Penalty
Summary
The facility failed to ensure that a resident who required assistance with activities of daily living (ADLs), specifically bathing and showering, was consistently offered and provided these services. The resident, who had diagnoses including heart failure, diabetes mellitus, and cellulitis, was assessed as having no cognitive impairment and required partial to moderate assistance with bathing and personal hygiene. Observations noted the resident with oily, unwashed hair, and interviews with staff confirmed that showers should be offered daily, with refusals documented and reported to the charge nurse. However, a review of the resident's ADL documentation revealed multiple dates in April where there was no record of the resident being offered or receiving a shower or bath. Staff interviews further confirmed the expectation that residents be offered showers daily and that refusals be properly documented. The Director of Staff Development acknowledged the lack of documentation for several days, and the Director of Nursing reiterated the facility's policy that residents should be offered showers or baths daily. The facility's policy also stated that residents are to be offered a shower at least once weekly and as requested. The absence of documentation and failure to offer or provide bathing assistance as required led to the deficiency.