Failure to Provide Scheduled Showers and Document Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for bathing received showers on their scheduled days according to their preferences. Medical record reviews, resident and staff interviews, and documentation audits revealed that three residents with intact cognition and significant physical limitations did not consistently receive scheduled showers. For example, one resident with multiple sclerosis, COPD, and atrial fibrillation, who required maximal assistance and mechanical lift transfers, had no shower documentation for two consecutive months and confirmed missed showers. Another resident with a right lower leg fracture and bipolar disorder, requiring moderate assistance, did not receive a scheduled shower, with no documentation or record of refusal, and also reported missed showers. A third resident, with a left femur fracture and polyneuropathy, dependent on a wheelchair and requiring substantial assistance, did not receive a scheduled shower, and documentation was incomplete. This resident stated that she had not received a shower for over a week and described waiting for staff assistance that never occurred. Staff interviews confirmed inconsistencies in documentation and communication regarding shower schedules, with some confusion between day and night shift responsibilities. The Director of Nursing verified the absence of required documentation for the affected residents on the specified dates. Facility policy required staff to document when showers were performed or refused, including the reason for refusal, but this was not consistently followed. The lack of documentation and missed showers for residents dependent on staff for bathing constituted a failure to honor resident choice and self-determination, as well as a failure to follow established care plans and facility procedures.