Failure to Provide Scheduled Bed Baths for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with severe mental impairment and a need for assistance with personal care received scheduled bed baths as required. Record review showed that the resident, diagnosed with Alzheimer’s disease and always incontinent, was care planned to receive bed baths three times per week on specific days and shifts. Documentation revealed that bed baths were not provided or recorded on several scheduled dates over a 30-day period, despite the resident’s inability to perform activities of daily living independently. Interviews with staff indicated a lack of clarity and communication regarding which staff were responsible for providing and documenting bed baths for the resident. Certified Nursing Assistants (CNAs) expressed uncertainty about why the resident had missed scheduled bed baths, with some staff unaware of the resident’s care needs or relying on outdated shower sheets instead of the electronic Plan of Care (POC) system. The resident’s representative and family members also reported that bed baths were often only provided after they requested them, and they monitored care through a camera in the resident’s room. Facility leadership, including the Clinical Specialist, Interim DON, and Administrator, acknowledged that showers and bed baths should be provided and documented according to the POC. However, discrepancies in documentation and staff communication led to missed care. The facility’s policy required that care and services for activities of daily living, including bathing, be provided based on comprehensive assessment and resident needs, but this was not consistently followed for the resident in question.