Failure to Consistently Provide and Document Scheduled Showers
Penalty
Summary
The facility failed to consistently provide and document scheduled showers for four of twelve sampled residents. Interviews and record reviews revealed that one resident's hygienic needs, including showering, shaving, hair trimming, and fingernail clipping, were not met frequently enough, resulting in a family member performing these tasks. Documentation showed gaps of up to seven days without a recorded shower or refusal, despite a set schedule. Another resident had only one documented shower refusal since admission, with no other records of completed or refused showers, and inconsistencies were found between paper and electronic documentation. Staff interviews confirmed issues with documentation practices, including reliance on paper records and double documentation, which contributed to the inconsistencies. Two additional residents expressed concerns about missed scheduled showers, with one reporting being left unattended in the shower room for 45 minutes without access to a pull cord, despite being wheelchair-bound. Review of the shower schedule and electronic health records showed significant gaps between documented showers, sometimes up to 14 days. Facility policy required showers to be provided per schedule or resident request, with documentation on both paper and electronic systems, and a specific process for documenting refusals. However, these protocols were not consistently followed, leading to incomplete records and unmet resident care needs.