Failure to Provide and Document Weekly Showers for Resident Requiring ADL Assistance
Penalty
Summary
A resident with diagnoses including dementia, cerebral infarction, and anxiety disorder, and a BIMS score indicating severe cognitive impairment, was identified as requiring set-up assistance for showers and had a care plan specifying assistance with activities of daily living (ADLs). The resident's care card scheduled weekly showers and noted a preference for showers. However, documentation review for a two-month period showed that out of nine scheduled weekly shower opportunities, the resident received only two showers. There was no documentation for the remaining seven scheduled shower days to indicate that a shower was provided, refused, rescheduled, or that alternative hygiene measures were offered. Further review of clinical records did not reveal any evidence that the resident refused showers on the missed dates, nor was there documentation of staff re-attempting or notifying the nurse as required by facility policy. The DON confirmed that if a shower is not documented as given or refused, it is considered not performed. The facility's Bathing/Shower Policy requires that each resident be offered a full bath or shower at least weekly, with staff responsible for assisting and ensuring safety throughout the process.