Failure to Provide and Document Scheduled Bathing and Showering for Dependent Residents
Penalty
Summary
The facility failed to consistently provide bathing and showering assistance to residents who were unable to perform these activities independently, as required by their care plans and facility policy. For four residents reviewed, documentation showed that scheduled showers or bed baths were either not provided or not properly documented as offered or refused. In several cases, the electronic health records (EHR) indicated that showers were only given once or twice in a 30-day period, with the remaining scheduled days marked as "Not Applicable" and lacking any indication of whether care was offered or declined. Specifically, one resident required extensive assistance with bathing and was scheduled for weekly showers, but only received two showers in a 30-day period, with no documentation of offers or refusals for the other days. Another resident, dependent on staff for bathing, received only one shower during a similar timeframe, again with no documentation of refusals. A third resident, who preferred bed baths and required limited assistance, did not receive any bed baths over a nearly two-week period, and there was no documentation to show if the care was offered or refused. A fourth resident, newly admitted and scheduled for weekly showers, did not receive a shower until 11 days after admission, with no documentation of offers or refusals during that period. Interviews with facility staff, including the unit manager RN, DON, and administrator, confirmed that refusals should have been documented and that the lack of documentation meant the care was not provided. The facility's policy required that residents unable to perform ADLs independently receive necessary services, and that refusals be documented along with communication of risks and benefits to the resident or representative. The failure to provide or document bathing and showering as scheduled constituted a deficiency in meeting residents' ADL needs.