Failure to Provide Bathing Services per Resident Preference Due to Staffing Issues
Penalty
Summary
The facility failed to provide bathing and showering services according to resident preferences for three residents who were dependent on staff for activities of daily living (ADL) care. Documentation and interviews revealed that residents did not consistently receive their preferred method or frequency of bathing, despite their preferences being documented in care plans and assessments. For example, one resident with severe cognitive impairment and total dependence on staff preferred a tub bath three times a week, but records showed they often received bed baths or showers instead, and there was no consistent documentation of bathing in the electronic medical record. Another resident, who was cognitively intact but fully dependent for transfers and required a mechanical lift, reported not receiving baths according to their preference of once a week. Paper shower sheets were frequently left unfilled, and electronic records only sporadically documented completed bathing tasks. A third resident, also fully dependent on staff for bathing and with a history of depression, reported not being bathed as frequently as preferred, with gaps in both paper and electronic documentation. This resident had also voiced concerns to staff about the issue. Interviews with multiple CNAs confirmed that resident showers were not regularly provided according to resident preferences, citing insufficient staffing as a primary reason. The Director of Nursing acknowledged awareness of staffing issues affecting the provision of care. Facility policies reviewed indicated that bathing should be consistent with resident choices and requests, but these were not followed in practice, resulting in the deficiency.