Failure to Provide Scheduled Showers per Resident Preference
Penalty
Summary
A deficiency was identified when a resident with quadriplegia and chronic pain, who was cognitively intact and dependent on staff for bathing and transfers, did not consistently receive showers as scheduled and per their preference. The resident's care plan, physician's orders, and the facility's shower schedule all indicated that the resident was to receive showers twice weekly, specifically on Wednesdays and Saturdays. However, clinical record review, resident interview, and staff interviews revealed that the resident had not received a shower for three weeks, instead receiving complete bed baths on scheduled shower days. Documentation showed the last shower was provided on 6/25/2025, with subsequent scheduled showers replaced by bed baths, and no evidence of shower refusals was found in the nursing notes. Staff interviews confirmed that showers were missed due to the resident's doctor appointments and that showers were not offered later in the day or on alternative days, as would be expected based on the resident's preference and facility policy. Nurse aides and an LPN could not consistently recall or document whether showers were provided or refused, and one nurse aide admitted to a documentation error regarding a shower. The Director of Nursing Services acknowledged that residents should be given the opportunity to have a shower at another time if missed due to appointments, but this was not done for the resident in question.