Failure to Provide Timely Showers and Support Resident Choice
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not providing timely bathing for four out of seven sampled residents. Facility policy required that residents receive showers in accordance with their preferences, care plans, and scheduled protocols, with staff responsible for assisting with bathing, performing skin assessments, and documenting these activities. However, documentation and interviews revealed that several residents did not receive showers as scheduled, with significant gaps between showers and incomplete records for October and November. Residents expressed dissatisfaction, noting that they felt unclean and that their preferences for at least weekly or biweekly showers were not honored. One resident with Alzheimer's disease and COPD required substantial assistance with ADLs and was care planned for weekly showers, but records showed only two showers in October and one in November, with a 16-day gap between some showers. Another resident, cognitively intact but needing assistance due to radiculopathy and dementia, was scheduled for weekly showers but experienced a 21-day gap between documented showers. A third resident, also cognitively intact and with a below-the-knee amputation, was care planned for twice-weekly showers but received only two showers in over a month. A fourth resident, recently admitted and with acute and chronic respiratory failure, reported going eleven days before being offered a shower, despite a preference for frequent showers and no care plan or nursing notes documenting bathing. Staff interviews confirmed that showers were often missed due to staffing shortages and lack of a dedicated shower aide. The shower schedule was posted daily, but aides reported difficulty completing showers when short-staffed, and documentation was inconsistent. Leadership acknowledged the issue, noting that the number of completed shower sheets was lower than expected and that improvements were needed. Residents' preferences for bathing were not consistently honored, and documentation of showers and skin assessments was incomplete or missing.