Failure to Honor Resident's Shower Preferences and Inadequate Documentation
Penalty
Summary
The facility failed to honor a resident's preference for shower date and time, as required by their care plan and facility policy. On the resident's scheduled shower day, she requested a shower but was told by the CNA that only a bed bath could be provided. The resident declined the bed bath, expressing her preference for a shower, but ultimately did not receive either a shower or a bed bath that day. The CNA later stated that due to being short-staffed, she was delayed in reaching the resident, who then requested only peri-area care and to be put to bed. The CNA did not document the refusal of the bed bath, nor did she inform the RN on duty of the resident's refusal, as required by facility protocol. Review of the resident's records confirmed her dependence on staff for bathing and her specific preference for shower days and times. The care plan emphasized the need for staff to be aware of and incorporate resident preferences into daily care. The facility's policy required that appropriate ADL care be provided in accordance with the resident's plan of care and preferences. However, the lack of communication and documentation by staff resulted in the resident's preferences not being honored and the required care not being provided or properly recorded.