Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
A resident with diagnoses including occlusion and stenosis of the right posterior cerebral artery, local skin infection, and dementia with behavioral disturbance was admitted and required partial to moderate assistance with bathing, as documented in the care plan and Minimum Data Set (MDS) assessment. The care plan included interventions for documenting refusals of care and cleaning the peri-area with each incontinence episode. During the review period, there was no documentation of the resident refusing showers or baths, and the resident was assessed as having intact cognition and not exhibiting rejection of care behaviors. Facility records, including the ADL Verification Worksheet and Bathing task log, showed that the resident received only one shower between July 23 and July 28, and then another on August 6, with a documented refusal on August 9. There was a nine-day lapse with no documentation of showers or refusals between July 28 and August 6, and several scheduled bathing dates were either marked as not assigned or had no documentation at all. Interviews with staff confirmed that showers are scheduled twice weekly and refusals are to be documented, but in this case, there was no evidence of refusals or completed showers for the identified period. The facility policy requires provision of ADL care, including hygiene, for residents unable to perform these tasks independently.