Failure to Provide and Document Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with paraplegia and a history of chronic pain, hypertension, and recent infection was not provided assistance with bathing or showering according to their care plan and preferences. The resident was assessed as cognitively intact and fully dependent on staff for bathing, with a care plan specifying two showers per week. Facility records and shower schedules indicated multiple missed or undocumented showers over a period of several weeks, with no evidence of resident refusal or proper documentation in the clinical record for those dates. Interviews with the resident and various staff members revealed inconsistencies in the assignment and documentation of bathing tasks. The resident reported not receiving scheduled showers and recounted a previous period of four weeks without a shower. Staff interviews confirmed that showers were to be documented on shower sheets and in the electronic record, with refusals also to be documented. However, several staff members either did not offer showers as scheduled or were not assigned to the resident, and one staff member's electronic documentation was found to be completed by someone else using their login credentials while they were not present in the facility. Review of facility policies confirmed that residents are to receive assistance with ADLs, including bathing, in accordance with their care plan and professional standards. Documentation of showers, including skin condition and refusals, was required but not consistently completed. The lack of proper documentation and failure to provide scheduled showers as per the resident's care plan constituted a failure to meet the resident's needs and preferences for personal hygiene.