Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) independently received the necessary assistance to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, four residents who required varying levels of assistance with bathing did not receive their scheduled showers, and there was no documentation available to confirm that these showers had been provided. The lack of records was confirmed by both the Director of Nursing (DON) and Assistant Director of Nursing (ADON), who were unable to produce any Bath/Shower Sheets for the month in question. Interviews with the affected residents revealed dissatisfaction with the care provided, particularly regarding the infrequency of showers and delayed response to call lights. Residents reported only receiving about one shower per week, despite being scheduled for more frequent bathing, and attributed this to staff shortages and high turnover among Certified Nursing Assistants (CNAs). Some residents stated that they only received showers after making complaints to the DON, and expressed discomfort with feeling unclean. The DON acknowledged receiving complaints about missed showers upon starting her position and confirmed that either showers were not being given or CNAs were not documenting them. The facility had recently experienced a change in ownership, which led to inconsistencies in the system used to track shower provision. The ADON also noted concerns about the lack of documentation and was unable to confirm whether residents were receiving their scheduled showers. The facility's policy required appropriate support and assistance with hygiene for residents unable to carry out ADLs independently, but this was not consistently provided or documented.