Failure to Provide Required Bathing Assistance to Dependent Residents
Penalty
Summary
Surveyors identified that the facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and showering, for seven out of eight residents reviewed. Multiple residents, each with significant medical conditions and varying levels of cognitive and physical impairment, did not receive showers at least once a week as required by facility policy and their individual care plans. Documentation was either missing, incomplete, or contained inconsistencies such as signatures from staff who were not present on the documented dates. In several cases, there was no evidence in the electronic medical record (EMR) or shower sheets to confirm that showers were provided, and some residents or their representatives reported not receiving showers since admission. Residents affected included individuals with diagnoses such as cerebral palsy, diabetes, depression, pressure injuries, and severe cognitive impairment. Interviews with residents and their representatives revealed that showers were not provided regularly, and in some cases, not at all. Observations by surveyors noted poor grooming, such as greasy hair, and residents expressed dissatisfaction with their hygiene care. For some residents, care plans indicated the importance of choosing their bathing method, but there was no documentation of these preferences being honored or of alternative hygiene measures being provided when showers were missed. The facility's own policies required that residents be offered showers at least weekly, either as requested or per the facility schedule, and that assistance be provided according to each resident's care plan. Despite this, there was a lack of consistent documentation and follow-through. In some instances, care plans were outdated or lacked specific instructions for staff, and there was no evidence of staff attempts to address refusals or barriers to bathing. The surveyors shared these concerns with facility leadership, but no explanations or additional documentation were provided to account for the missed showers or to demonstrate that residents' hygiene needs were being met as required.