Failure to Provide Required Bathing and Hygiene Assistance Due to Staffing Shortages
Penalty
Summary
Facility staff failed to provide necessary care and assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, to ten residents who were dependent on staff for these tasks. Review of facility records, including Minimum Data Sets (MDS), care plans, and shower sheets, revealed that multiple residents received significantly fewer baths or showers than required by their care plans and facility policy. For example, several residents received only one or two baths/showers per month, despite being assessed as needing assistance with bathing at least twice weekly and as needed. Documentation for some residents showed entire weeks or months without any recorded bathing or showering. Interviews with residents confirmed dissatisfaction with the frequency of showers, with some expressing a desire for more regular bathing and noting that their families had raised concerns with staff. One resident reported receiving a shower for the first time in a long period and noted that staff put dirty clothes back on after bathing, despite the availability of clean clothing. These observations were corroborated by staff interviews, where multiple CNAs and a CMT reported chronic understaffing, which prevented them from completing showers, maintaining good hygiene, or providing oral care. Staff described prioritizing other care tasks, such as toileting, due to time constraints, and acknowledged that showers were often delayed or omitted entirely. Nursing staff, including an LPN and the Director of Nursing, acknowledged that showers were not being completed as required, citing high resident acuity and insufficient staffing as contributing factors. The DON reported being aware of the issue and described attempts to track and reschedule missed showers, but the documentation and staff interviews indicated that the deficiency persisted. The failure to provide regular bathing and hygiene assistance was directly linked to inadequate staffing and time management, as reported by both direct care staff and nursing leadership.