Failure to Provide and Document Scheduled Showers and Incontinent Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living independently were consistently offered and/or received showers on their assigned shower days. Multiple residents reported not receiving showers for extended periods, with some stating they had only received bed baths and never refused showers. Documentation for several residents showed either a lack of showers provided, missing records of showers being offered or refused, or entries marked as 'not applicable' on scheduled shower days. In some cases, residents' care plans indicated significant self-care deficits, such as paraplegia and impaired mobility, further emphasizing their dependence on staff for personal hygiene. Interviews with residents and staff revealed that staffing shortages directly impacted the ability to provide showers as scheduled. Staff reported that when the number of geriatric nursing assistants (GNAs) on shift was insufficient, showers could not be given, especially for residents requiring assistance from two GNAs. Documentation inconsistencies were noted, with some residents receiving only bed baths for months and others having sporadic or undocumented shower provision. Residents expressed dissatisfaction, stating they were not offered showers or were told by staff that there was not enough time to provide them. Additionally, there were documented instances of residents not receiving timely incontinent care, as evidenced by bowel and bladder records showing missed care on multiple shifts. Family members also reported finding their loved ones soiled during visits. These findings collectively demonstrate a pattern of inadequate assistance with activities of daily living, specifically related to bathing and personal hygiene, due to both documentation failures and staffing issues.