Failure to Provide Preferred Bathing Method Due to Equipment Shortages and Inadequate Documentation
Penalty
Summary
The facility failed to ensure that two residents received their preferred method of bathing, specifically showers, as documented in their care plans and expressed preferences. Both residents had significant physical limitations, including dependence on staff for transfers and hygiene, and required the use of a Hoyer lift with bariatric pads for safe transfers to the shower bed. Documentation in the medical records and CNA task logs did not differentiate between showers, bed baths, or refusals, making it unclear what type of bathing was actually provided. Staff interviews confirmed that there were ongoing issues with the availability and tracking of Hoyer lift pads, which directly impacted the ability to provide showers as requested by the residents. Resident #12, with diagnoses including diabetes, anxiety, depression, osteoarthritis, and chronic pain syndrome, was cognitively intact and dependent on staff for personal hygiene. She reported never refusing a shower, but stated that staff often told her there were no Hoyer lift pads available, resulting in her receiving only partial bed baths without hair washing. Staff interviews corroborated the shortage of Hoyer pads and the lack of clear documentation regarding the type of bathing provided. The unit manager and LPN were unable to confirm or provide evidence of completed showers or bed baths, and could not consistently locate the necessary equipment for transfers. Resident #23, who had multiple sclerosis, morbid obesity, hemiplegia, and was non-ambulatory, also required total staff assistance and preferred showers as documented in her care plan. Review of her records showed missed showers on scheduled days without documentation of refusals, and staff interviews revealed inconsistent documentation practices. The resident reported not receiving showers for months and only being provided with bed baths, which was visually supported by observations of unwashed hair. Staff were unable to confirm when the last shower was provided, and the necessary Hoyer pads for transfer were missing for about a week, further preventing the provision of showers.