Failure to Provide Scheduled Showers and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide scheduled showers to two residents, resulting in nine missed opportunities for personal hygiene care. One resident, who was cognitively intact and scheduled for showers twice a week, did not receive showers on multiple scheduled days and reported feeling dirty, neglected, and isolated. The resident stated she had not refused any showers and was not given a reason for the missed care. Another resident, with moderate cognitive impairment and a diagnosis of major depressive disorder, also missed several scheduled showers and expressed feeling dirty and gross due to the lack of personal hygiene care. Record reviews confirmed that both residents had missed multiple scheduled showers, with documentation either absent or marked as not applicable for those dates. There were no progress notes or care plans addressing missed or refused showers in either resident's medical record. Staff interviews revealed that showers were to be documented in both a shower binder and the electronic medical record, and that blank spaces or 'N/A' entries indicated missed showers. Staff acknowledged the importance of showers for resident assessment and dignity, and confirmed that there were no external factors, such as water or equipment issues, that would have prevented showers from being given during the relevant period. Facility leadership, including the Director of Staff Development, Infection Preventionist, and Director of Nursing, stated that it was their expectation for staff to complete and document showers as scheduled, escalate missed showers, and ensure resident rights to personal hygiene were honored. However, the lack of documentation, absence of progress notes, and failure to address missed showers in care plans demonstrated a breakdown in the facility's processes, resulting in residents not receiving the care to which they were entitled.