Failure to Provide and Document Assistance with Showers for Dependent Residents
Penalty
Summary
Facility staff failed to provide adequate care and assistance with activities of daily living, specifically showers, for six residents who required such support. Review of facility records and interviews revealed that these residents, many of whom had moderate to severe cognitive impairment and required substantial to total assistance for personal hygiene and bathing, did not consistently receive showers as care planned or as per their preferences. Documentation in the electronic medical record (EMR) was often missing, with several residents going weeks without a documented shower or any record of refusal, despite their care plans indicating a need for regular assistance. Observations on the survey date showed multiple residents with greasy, unkempt hair, and in some cases, soiled clothing, indicating a lack of basic hygiene care. Interviews with the affected residents confirmed that they had not received showers for extended periods, with some expressing feelings of discomfort and uncleanliness. Residents reported that staff were supposed to assist them with showers at least once or twice per week, but this was not occurring, and some residents attempted to clean themselves with washcloths due to the lack of assistance. Staff interviews revealed that the designated shower aide was unable to complete all required showers due to time constraints and staffing shortages, particularly for residents needing two-person assistance. Staff also admitted to not always documenting showers or refusals in the EMR when busy. The facility lacked a specific shower policy, and leadership acknowledged that they had not recently reviewed shower documentation, relying instead on visual monitoring and verbal direction to staff. These actions and inactions led to a failure to meet the basic hygiene needs of dependent residents.