Failure to Provide Scheduled Shower and Accurate Documentation for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who required substantial to maximum assistance with activities of daily living, including bathing, did not receive a scheduled shower. The resident, a female with moderately impaired cognition, hemiparesis due to stroke, contractures, and other medical conditions, was scheduled to receive showers on specific days and shifts. Documentation indicated that her shower was marked as completed by a CNA on the scheduled day, but interviews and progress notes revealed that the shower was not actually provided. The resident reported to staff that her shower was missed, and this was confirmed through interviews with multiple staff members. The CNA responsible for documenting the shower admitted to marking it as completed based on an assumption rather than direct knowledge or confirmation that the shower had been given. The CNA also stated that she did not offer the shower because she believed another aide had already provided it, and later realized this was a mistake. The resident did not report the missed shower to the charge nurse at the time, stating that previous complaints had not resulted in changes. Facility records, including the care plan and shower schedule, outlined the expectation that showers be provided as scheduled and refusals be documented and reported to nursing staff. However, in this instance, the required care was not delivered, and the documentation did not accurately reflect the care provided. The failure to provide the scheduled shower and the inaccurate documentation were confirmed through observation, record review, and staff and resident interviews.