Failure to Provide Showers and Timely Morning Care Due to Hoyer Lift Unavailability
Penalty
Summary
The facility failed to provide activities of daily living (ADLs) related to hygiene and bathing in accordance with residents' needs and preferences for four out of five sampled residents. Multiple residents with significant physical impairments, including paraplegia, hemiplegia, quadriplegia, morbid obesity, and Parkinson's disease, were dependent on staff for transfers, personal hygiene, and dressing. These residents had intact cognitive skills and were able to express their preferences for showers over bed baths, stating that showers made them feel cleaner and more dignified. Residents reported that they were unable to receive showers as preferred due to the unavailability of a Hoyer lift, which was required for safe transfers. Staff interviews confirmed that only one Hoyer lift was operational across three nursing units during the past week, resulting in delays in morning care routines, substitution of bed baths for showers, and residents getting out of bed later than usual. This equipment shortage led to residents arriving late to scheduled activities and, in some cases, missing the start of these activities. The facility's policy required that residents be offered showers at least once weekly and upon request. However, due to the limited availability of functioning lifts, staff were unable to meet these preferences and needs, directly impacting residents' hygiene routines and psychosocial well-being. Maintenance staff confirmed that the shortage was due to a malfunctioning remote and a new lift awaiting calibration, which further contributed to the delays and substitution of care.