Failure to Provide and Document Daily Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs), specifically bathing and showers, were provided and properly documented for residents who were unable to perform these tasks independently. For one resident with multiple complex medical conditions, including paraplegia, dementia, and a history of pressure ulcers, the clinical record and care plan indicated a need for total assistance with bathing. However, a review of the point of care documentation for July and August showed inconsistent entries for bathing, with several days lacking documentation of any bathing or shower, and no records indicating resident refusal. Similarly, another resident with severe cognitive impairment and total dependence for bathing had a care plan specifying preferred shower days. Documentation for July, August, and September revealed irregular entries for partial or complete bed baths and showers, with gaps in daily bathing records and no documentation of refusals. Staff interviews confirmed that refusals should be documented and reported, but no such documentation was found. The facility's policy required appropriate support and assistance with hygiene for residents unable to perform ADLs, but this was not consistently provided or recorded.