Failure to Provide Scheduled Showers and Bed Baths for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, for three residents who were dependent on staff for these tasks. Scheduled showers and bed baths were not consistently provided according to the facility's own shower schedule and care plans. For example, one resident who was dependent for all ADLs and had significant medical needs, including pressure ulcers and cognitive impairment, did not receive scheduled bed baths on multiple occasions, with documentation showing only two bed baths in a 30-day period. Another resident, who was cognitively intact but physically impaired and required maximal assistance for bathing and dressing, did not receive scheduled showers for extended periods, including gaps of up to 12 days without a shower. This resident reported to surveyors that she had not refused showers, had filed grievances, and sometimes experienced body odor due to missed showers. She also expressed concerns about staff not returning to assist her after promising to do so, particularly when two staff members were needed for safe transfers. A third resident, who was totally dependent on staff for bathing due to impaired balance and limited mobility, also missed multiple scheduled showers and filed grievances about not receiving them. Interviews with staff revealed inconsistencies in documentation, issues with access to the electronic charting system, and a lack of clarity regarding responsibility for entering shower records. Observations confirmed that shower documentation was incomplete and not consistently entered into the electronic system, with paper records left unfiled. The facility's own ADL policy required daily documentation and regular monitoring, which was not followed.