Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) independently received the necessary services to maintain grooming, personal, and oral hygiene. Specifically, nine residents reviewed for ADL care did not receive scheduled showers or adequate assistance with hygiene. Documentation and interviews revealed that showers were missed or not provided as scheduled, and in several cases, residents went a week or more without a bath. Residents and their representatives reported long wait times for assistance, lack of staff availability, and instances where staff did not return to provide care after initially responding to call lights. Multiple residents with significant medical conditions, such as acute respiratory failure, diabetes, cognitive deficits, paralysis, and pressure ulcers, were affected by these lapses. For example, one resident with total dependence for toileting and bathing reported only receiving one shower per week instead of the scheduled three, and another resident with quadriplegia and a stage 4 pressure ulcer stated that he had not received a bath in a week. Observations confirmed that some residents remained in the same clothes for several days, had unkempt hair, and appeared unwashed. Staff interviews indicated confusion about shower assignments, documentation procedures, and responsibility for equipment maintenance, such as charging mechanical lifts. Record reviews showed inconsistent or missing documentation of ADL care, including bathing, toileting, and repositioning. Staff interviews further revealed that CNAs were often unsure of their duties, lacked supervision, and cited chronic understaffing as a barrier to providing scheduled care. The Director of Nursing and other supervisory staff acknowledged that showers and baths were to be documented and monitored but were unaware of the extent of missed care and documentation lapses. No ADL policy was provided upon request during the survey.