Failure to Provide Scheduled Baths or Showers to Multiple Residents
Penalty
Summary
The facility failed to provide scheduled baths or showers to three out of four residents reviewed, despite care plans and facility protocols indicating the required frequency. Electronic Health Record (EHR) reviews showed that one resident, who was cognitively intact and required substantial assistance, was scheduled for three baths per week but only received 30 out of 48 expected baths over a four-month period. Staff interviews confirmed that baths were sometimes missed due to staffing shortages, and there was no documentation of resident refusals for the missed baths in the EHR or on bath sheets, despite staff claims that refusals would be recorded. Another resident, also cognitively intact and dependent on staff for bathing, received only 8 out of 18 scheduled baths over a two-month period, with no refusals documented in the EHR. A third resident, similarly dependent, received 17 out of 33 scheduled baths over a four-month period, with only one refusal documented. The facility's policy required that residents be assisted with bathing according to their care plans and preferences, but the records and interviews indicated that this standard was not consistently met. The Director of Nursing (DON) and other staff acknowledged that baths were missed and that the facility had identified this as a concern. The DON confirmed that the expectation was for residents to receive at least two baths per week, and that the documentation did not reflect refusals for the missed baths. The administrator also acknowledged the issue, stating that resident preferences were considered in care planning, but that the scheduled baths were not consistently provided as required.