Failure to Provide and Document Assistance with Bathing and Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing and personal hygiene, to two residents who were unable to perform these tasks independently. Both residents had moderate cognitive impairment and required substantial or maximal assistance with bathing, as documented in their care plans and Minimum Data Set (MDS) assessments. Despite these documented needs, there was a lack of recorded evidence that bathing was provided during specific periods of their stays, and no documentation was found indicating that the residents refused or were unavailable for bathing during those times. For one resident, there was no documentation of bathing from admission through a week-long period, and for the other, no bathing documentation was found during the initial days of admission or for a week following a hospital readmission, except for one documented refusal. Progress notes did not contain any information about bathing or refusals during these gaps. Family members of both residents reported concerns about the residents' hygiene, with one family member stating the resident was consistently unclean and expressing distress over the lack of care provided. Interviews with facility staff, including the DON, ADON, and Unit Manager, confirmed that the only place for documenting bathing was the electronic medical record and that there had been issues with staff not documenting showers properly. Staff described the process for handling refusals and oversight responsibilities, but acknowledged that documentation and monitoring practices had only recently been updated. The facility's policy required necessary services for residents unable to perform ADLs, but the records and interviews indicated these services were not consistently provided or documented for the two residents in question.