Failure to Provide Required Bathing Frequency
Penalty
Summary
The facility failed to ensure that residents received two showers per week as required, affecting five residents reviewed for bathing. Medical record reviews, observations, and interviews revealed that several residents, including those with severe cognitive impairment, dependence for activities of daily living, and significant medical conditions such as encephalopathy, dementia, end stage renal disease, and aftercare for fractures, did not receive the required number of showers. For example, one resident received only two showers out of eight opportunities, while another received only two out of eleven, with some refusals documented but most missed showers unexplained. Residents were not out to the hospital during these periods, indicating the missed showers occurred while in the facility. Interviews with residents and staff confirmed the lack of adequate bathing, with one resident reporting that showers were missed due to insufficient aide staffing, particularly at night, and being observed with an odor of urine and unkempt appearance. Review of facility policy indicated that bathing is intended to promote cleanliness, comfort, and skin observation, but documentation and staff interviews verified that the required bathing frequency was not maintained for the affected residents.