Failure to Provide Showers According to Resident Preferences
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not providing showers as preferred for two residents who were dependent on staff for activities of daily living (ADLs). Resident B, with diagnoses including diabetes mellitus, major depressive disorder, anxiety disorder, glaucoma, cataract, hearing loss, and anorexia, was assessed as severely impaired for daily decision making and required staff assistance for showers. Documentation indicated that it was very important for this resident to have showers, and the care plan specified showers twice weekly. However, shower reports showed that Resident B received complete bed baths instead of showers on multiple occasions across March, April, and May, despite the resident's stated preference and care plan interventions. Similarly, Resident E, who had dementia, chronic kidney disease, repeated falls, and chronic pain syndrome, was also severely cognitively impaired and dependent on staff for showering. The care plan and preference documentation indicated a preference for showers twice weekly. Despite this, shower reports revealed that Resident E received bed baths instead of showers on several documented dates in April and May. Interviews with staff and family confirmed awareness of the residents' preferences, but the facility did not consistently provide showers as preferred.