Failure to Honor Resident Shower Preferences and Care Plans
Penalty
Summary
The facility failed to honor and facilitate resident choices regarding shower schedules for two residents out of a sample of four, as required by their care plans and expressed preferences. One resident, who was cognitively intact and independent in activities of daily living but required supervision for showers, consistently requested showers on Saturdays and Wednesday mornings to accommodate family visits and personal appointments. Despite these requests, the resident continued to receive showers on Mondays and Thursdays, and on one occasion, did not receive a shower at all after waiting the entire day. Documentation inconsistencies were also noted, with staff marking a shower as given when it was not provided. Another resident, also cognitively intact but fully dependent on staff for all activities of daily living due to end-stage multiple sclerosis and quadriplegia, was scheduled for one shower per week on Sundays. The resident reported that if a Sunday shower was missed, it was not rescheduled, resulting in missed opportunities for personal hygiene. On at least two occasions, the resident did not receive a shower as scheduled, including one instance where the preferred shower chair was unavailable and alternative options were declined by the resident. Staff interviews revealed a lack of awareness regarding the residents' specific preferences and missed showers. The DON stated that the facility attempted to honor shower requests as staffing allowed but was not aware of the residents' specific needs or the missed showers. Documentation errors and communication gaps contributed to the failure to provide showers according to resident choice and care plans.