Failure to Provide Scheduled Shower for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living did not receive a scheduled shower as required by their care plan and physician orders. The resident reported during a council meeting that they had not received their scheduled shower the previous day, and this was confirmed through observation and interviews. The resident stated that staff typically provided showers on scheduled days without the need for a request. Review of the medical record and care plan confirmed the resident's need for assistance and the established schedule for showers. Further investigation revealed that documentation did not indicate the shower was provided as scheduled, and staff interviews confirmed that residents should not have to request their scheduled showers. The facility's policy required documentation of showers and notification of refusals, but there was no evidence that the missed shower was documented or that a refusal occurred. The facility acknowledged that the resident's scheduled shower was missed, confirming the failure to provide necessary services to maintain personal hygiene as required.
Plan Of Correction
483.24(a)(2) ADL Care Provided for Dependent Residents 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 122 was assessed by the Director of Nursing on 04/17/25. R122 was offered a [R] at that time, accepted, and received a [R]. R122 did not present any additional concerns when asked. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing or designee in-serviced licensed nursing staff and certified nursing aides on the center policy for offering and providing showers to all residents. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Director of Nursing or designee will conduct audits on 10 residents to confirm that they were offered and received their showers. Audits will be conducted weekly for 4 weeks, then every other week for 4 weeks, and then monthly for 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.