Failure to Provide and Document Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident was offered or provided showers according to his scheduled shower days. Clinical record review showed that the resident, who had chronic obstructive pulmonary disease, pneumonia, and generalized muscle weakness, required substantial to maximal assistance with bathing and was cognitively intact. Documentation for several scheduled shower days over a two-month period was either missing or marked as not applicable, with no evidence that showers were offered or provided on those days, nor that make-up showers were given on alternate days. Only one instance was documented where the resident refused a shower and accepted a bed bath instead, but there was no evidence of refusals or alternative care for the other missed dates. Staff interviews confirmed that the expectation was for residents to be offered showers twice weekly per the schedule, and that refusals should be documented in the electronic health record or on shower sheets. However, the facility was unable to provide shower sheets for the relevant period, and the Director of Nursing acknowledged that documentation could be lacking, as shower sheets were only retained for a month. Review of facility policies indicated that all bathing and shower care, including refusals and skin observations, should be documented, but this was not consistently done for the resident in question.