Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for activities of daily living (ADLs), specifically bathing, received showers or complete bed baths as scheduled. Multiple residents reported or were observed to have gone extended periods without showers, despite care plans and preferences indicating the need for assistance with bathing at least twice per week, with partial baths in between. Documentation and interviews revealed that showers were missed on several scheduled days for seven out of eight residents reviewed, and in some cases, residents' preferences for shower timing and frequency were not honored. Residents affected included those with cognitive impairments such as Alzheimer's disease and dementia, as well as those with physical limitations like quadriplegia and major depressive disorder. Observations included residents with unbrushed, greasy, or oily hair, and direct complaints from residents about not receiving showers for up to two or three weeks. Clinical records and care plans consistently documented the need for staff assistance with bathing, and residents' preferences for shower frequency and timing were noted but not consistently followed. Review of the facility's documentation systems, including Point of Care (POC) charting and shower sheets, showed gaps where showers or bed baths were neither provided nor documented as refused. Staff interviews confirmed that information was sometimes not transferred correctly between documentation systems, and that reattempts or alternative shower times were not always offered when a resident initially refused care. The facility's policy on resident rights emphasized dignity, respect, and honoring resident schedules, but these standards were not met in practice for the residents reviewed.