Failure to Provide Scheduled Bathing and Incontinence Care to Dependent Residents
Penalty
Summary
Facility staff failed to provide scheduled bathing and incontinence care to two dependent residents, resulting in deficiencies in activities of daily living (ADL) care. One resident, admitted with hemiplegia and Parkinson's disease, was assessed as dependent for bathing and had a scheduled shower routine documented in the care plan. However, facility records showed a missed scheduled shower, with no documentation of refusal or explanation for the omission. Interviews with staff confirmed that showers are to be documented in the electronic medical record, but the required documentation was missing for the specified date. Another resident, with diagnoses including dementia, schizophrenia, and total dependence for ADLs, was found to have multiple missed showers and incontinence care episodes over several months. ADL documentation for this resident showed entries marked as 'not applicable' or left blank on scheduled shower and incontinence care dates, with no evidence of refusals. Staff interviews revealed that the resident was rarely showered, often appeared disarrayed, and was always incontinent, requiring frequent assistance. Multiple staff members reported concerns about the resident's hygiene, including persistent urine odor and infrequent clothing changes, which were not addressed despite being reported to administration. The facility's own policy requires that residents unable to perform ADLs receive necessary services to maintain hygiene and grooming. Despite this, documentation and staff interviews confirmed that dependent residents did not consistently receive scheduled showers or incontinence care, and there was a lack of proper recordkeeping to justify missed care. Administrative staff were made aware of these findings during the survey, but no further information was provided prior to exit.