Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for activities of daily living (ADL), specifically bathing and showering, received showers as required by their care plans and facility policy. Multiple residents with varying degrees of cognitive and physical impairment, including those with diagnoses such as renal dialysis dependence, hemiplegia, dementia, and chronic obstructive pulmonary disease, were scheduled for regular showers but did not consistently receive them. Documentation revealed missed showers, incomplete records, and instances where showers were marked as 'not applicable' without evidence of refusal or alternative care, such as bed baths. Interviews with residents and staff confirmed that showers were not provided as scheduled, with some residents reporting not having been bathed for weeks and staff acknowledging the lack of proper documentation and completion of scheduled showers. In several cases, the Minimum Data Set (MDS) assessments marked bathing as 'not applicable' because the residents had not been bathed during the look-back period, further confirming the lack of care. Observations also noted poor hygiene, such as oily hair and dirty nails, in residents who had missed scheduled showers. The deficiency was widespread, affecting a significant number of residents reviewed for showers, and was corroborated by both record review and staff interviews. Facility policy required at least two showers per week for dependent residents, but this standard was not met for many individuals. The lack of documentation for missed showers, refusals, or alternative bathing methods indicated a systemic failure to provide and record essential ADL care as required.