Failure to Provide Scheduled Showers Due to Staffing and Process Gaps
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care, specifically showers, to dependent residents as required. Two residents with significant physical impairments and care needs did not receive scheduled showers on multiple occasions. Documentation showed missed showers on several scheduled days, and both residents confirmed in interviews that they had not been receiving showers regularly. One resident reported that showers were often missed due to staff shortages, and that make-up showers were not provided if a scheduled shower was missed. Observations noted that while there was no body odor, one resident had greasy, uncombed hair, indicating a lack of personal hygiene care. Interviews with the shower team nurse aides (NAs) revealed that they were frequently pulled from their shower duties to work on the floor when the facility was short-staffed. The NAs stated that when they were reassigned, showers were not given by floor staff, and missed showers were not rescheduled. The shower team reported that even when not pulled, the workload was too high for two NAs to complete all scheduled showers, and they had requested additional help from facility leadership. Other staff, including the unit clerk and additional NAs, confirmed that showers were not provided when the shower team was reassigned, and that this was a frequent occurrence. Facility leadership, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator, acknowledged that there was no process in place to ensure residents received showers when the shower team was pulled to the floor. The ADON was aware that residents did not receive showers in these situations and that some residents had complained. The DON and Administrator were not fully aware of the extent of the missed showers until the issue was brought to their attention. The lack of a contingency plan and insufficient staffing directly led to the failure to provide required ADL care for dependent residents.