Failure to Provide Scheduled Showers and Document Bathing Care
Penalty
Summary
The facility failed to ensure that residents received showers as scheduled and according to their preferences, as evidenced by the experiences of two residents who required limited or moderate assistance with bathing. One resident, admitted with diagnoses including heart disease, a history of falls, and chronic obstructive pulmonary disease, was independent in several activities of daily living but required limited staff assistance for personal hygiene and physical help only with transfers for bathing. Despite being scheduled for showers twice weekly, documentation showed only two recorded bathing events over a three-month period, with one being a bed bath and another date left blank. The resident reported not receiving scheduled showers and stated that his family had to assist with shaving due to lack of staff support. Facility leadership confirmed the lack of documentation for additional showers during this period. Another resident, with diagnoses such as adjustment disorder, chronic respiratory failure, morbid obesity, dysphagia, and depression, and who was cognitively intact, required moderate staff assistance for bathing, dressing, and personal hygiene. Although scheduled for showers twice weekly, facility records could only verify eight showers out of 21 scheduled opportunities. The resident reported not receiving scheduled showers and being told to wash up at the sink. Staff interviews revealed that when the shower aide was reassigned to other duties, scheduled showers were not completed, and communication lapses occurred regarding missed showers. The Director of Clinical Services confirmed that showers were not being provided as scheduled. Facility policy required documentation of showers or refusals, but this was not consistently followed.