Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
A deficiency occurred when a resident with Guillain-Barre Syndrome and muscle weakness, who required assistance with activities of daily living (ADLs) such as bathing and grooming, did not consistently receive scheduled showers. The resident's care plan specified the need for assistance with bathing, and the Minimum Data Set (MDS) assessment confirmed the resident required partial to moderate assistance for bathing and transfers. Despite being cognitively intact, the resident reported missing two scheduled showers and stated that staff told them the day staff were too busy to provide the shower. Documentation in the medical record confirmed the absence of showers on the scheduled dates, and only one shower was documented during the review period, with bed baths provided on other dates. Multiple staff interviews corroborated the resident's complaint, with nurse aides and the unit manager acknowledging the missed showers and the resident's requests. Staff indicated that the resident sometimes requested showers at times when adequate staff were not available to assist, and there was confusion or lack of follow-up regarding the resident's complaints. Review of nursing progress notes and behavior monitoring did not identify any care refusal or behaviors that would have prevented the resident from receiving showers. Facility policy required real-time documentation of ADL care, but the medical record did not reflect that showers were provided as scheduled.