Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers for multiple residents who were unable to perform activities of daily living (ADLs) independently. During a resident council meeting, several residents reported not receiving showers on a consistent basis, with one resident stating they sometimes went up to two weeks without a shower, despite being scheduled for two showers per week. Another resident indicated they received only one shower per week, and a third noted that showers were often canceled when the facility was short-staffed. Direct observations and interviews confirmed these reports. One resident was found in bed with uncombed, greasy hair and stated they had missed a scheduled shower due to short staffing, at one point going 18 days without a shower. Medical records for this resident showed that out of 25 scheduled shower opportunities, 23 were missed, with a documented period of 19 consecutive days without a shower. This resident had a history of type 2 diabetes mellitus and moderately impaired cognition. Another resident, who was cognitively intact and had a diagnosis of osteomyelitis, was observed complaining about not having had a shower for about 10 days and was attempting to relieve itching with wet washcloths. Documentation confirmed that this resident had not received a shower for at least 16 days. The Director of Nursing acknowledged that while showers were scheduled, there was a breakdown in communication between the computer system and CNAs, resulting in many missed showers. Facility policy required the provision of hygiene care, including bathing, in accordance with resident assessments and preferences, but this was not consistently followed for the affected residents.