Failure to Provide and Document Required Showering Assistance
Penalty
Summary
The facility failed to provide and document regular showering assistance for a resident who required help with activities of daily living due to impaired mobility from osteoarthritis. According to the facility's own policy, showers are to be given to promote cleanliness, comfort, and to observe skin condition, with specific documentation required for each shower, including date, time, staff involved, skin assessment, and resident tolerance. The resident was scheduled to receive showers twice weekly, but only six showers were documented over a period in which 23 should have occurred. Interviews with the DON, medical records staff, and a CNA confirmed that showers were to be documented on paper forms and uploaded into the electronic medical record. However, there were significant gaps in the documentation, and the DON acknowledged that if a shower was not documented, it was considered not done. The lack of documentation and the inability to provide records for the majority of scheduled showers indicated that the facility did not consistently provide or record the required showering assistance for the resident.