Failure to Provide and Document Scheduled Showers
Penalty
Summary
A resident with diagnoses including diabetes and congestive heart failure, who was cognitively intact, did not receive scheduled showers for approximately 12 weeks. The resident reported not refusing showers and expressed a desire to have them, stating that showers were not being offered and that it depended on staffing levels. Interviews with staff confirmed that showers were scheduled twice weekly and that refusals were to be documented by CNAs and communicated to nurses, who would then document in the electronic medical record. However, review of CNA documentation, nurses' progress notes, and shower checklists over a two-month period showed no evidence that the resident received or refused showers during this time. Further interviews with nursing staff and the Director of Nursing revealed a lack of documentation regarding the resident's showers or refusals, and the only information available was the shower schedule on assignment sheets. The facility failed to provide necessary care and services related to showers, as required, and did not maintain adequate records to demonstrate that the resident was offered or received showers according to their care plan.