Failure to Honor Resident's Shower Preference Due to Delayed Equipment Procurement
Penalty
Summary
The facility failed to honor a resident's personal care preferences by not providing showers as requested, instead only offering bed baths since the resident's admission. The resident, who was cognitively intact and dependent on staff for bathing due to right-sided hemiplegia following a stroke, repeatedly expressed a preference for showers, stating that bed baths were degrading and did not adequately clean their long hair. Family members also voiced concerns to staff and the resident's physician about the lack of showers and the use of dry shampoo, which left the resident's hair greasy and covered in residue. Despite the resident's care plan and care card indicating a need for staff assistance and a mechanical lift for shower transfers, documentation failed to show that any showers were provided. Staff interviews revealed that although safe shower chairs were available for residents with similar needs, the primary CNA and facility administration believed there was no appropriate shower chair for this resident. Occupational therapy records indicated that showering was a goal, but the resident was dependent and unsafe for showers without specialized equipment. The occupational therapist reported notifying her supervisor months prior about the need for a suitable chair, and a new chair was only recently obtained but not yet evaluated for use. Further interviews with facility leadership confirmed awareness of the resident's unmet preference and acknowledged significant delays in ordering and modifying the necessary shower chair. The Regional Director of Rehab admitted that the process to research, order, and modify the chair took several months longer than acceptable, resulting in the resident being denied showers for an extended period. The DON stated that all residents should be able to choose between a bath or shower and that equipment should be obtained in a timely manner, but was unaware of the timeline for this request.