Failure to Provide Showers According to Resident Preference and Facility Policy
Penalty
Summary
The facility failed to honor and facilitate resident choice regarding showering for five residents who required staff assistance. Multiple residents, including those with significant physical limitations, cognitive impairments, and at risk for skin issues, did not receive showers according to their preferences or the facility's stated policy. Documentation and interviews revealed that some residents received only one shower in a 30-day period, with gaps of up to three weeks or more between showers, despite expressing a desire for more frequent bathing and reporting discomfort such as itching and feeling unclean. Residents reported that when they requested showers, staff often told them there was not enough time or that there was no designated shower aide available. Staff interviews confirmed that the facility had recently removed the designated shower aide position, leaving CNAs responsible for showers in addition to their other duties. Staff were unclear about which residents needed showers, when showers were last provided, and how to access or use a shower schedule. Several staff members indicated that the workload was too heavy to complete all required showers, and that management had not provided adequate support or clear direction regarding shower scheduling and documentation. The lack of a consistent shower schedule, insufficient staffing, and poor communication among staff led to residents not receiving showers as per their preferences or care plans. Residents and staff both reported frustration with the situation, and the issue was brought to the attention of nursing and administrative leadership. Despite the facility's policy to provide showers per resident request or schedule, the failure to maintain a system for tracking and ensuring showers resulted in unmet hygiene needs for multiple residents.