Failure to Accommodate Resident Preferences for Showers and Pressure-Reducing Cushion
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents regarding their care routines. One resident, who had diagnoses including cerebral palsy, diabetes, cerebral infarction with hemiplegia and hemiparesis, anxiety, and major depressive disorder, was dependent on staff for showering and had a documented preference and care plan for showers three times a week. Despite this, records showed that the resident frequently received bed baths instead of showers on multiple scheduled days over two months, and the resident reported that only one CNA would provide showers while others gave bed baths due to the need for a mechanical lift. Another resident, with diagnoses of schizophrenia and chronic kidney disease, had a care plan indicating the need for a pressure-reducing cushion while in a wheelchair due to risk for skin breakdown. During observations, the resident was found both with and without the cushion in place, and stated he had never used a cushion in his wheelchair. The DON confirmed that the resident's cushion was unavailable at one point because it was drying after being washed, and that spare cushions were available but not used by staff. Facility policy required reasonable accommodation of resident needs and preferences.