Failure to Provide and Document Showers for Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, as documented by a Brief Interview of Mental Status score of 9/15, did not receive scheduled showers as required by facility policy. The resident required substantial to maximal assistance for personal hygiene and was scheduled to receive showers twice weekly. Review of the resident's shower documentation for the month revealed no entries indicating that showers were provided, nor any documentation of refusals or alternative hygiene measures such as bed baths. Interviews with staff confirmed that the resident had not received showers for an extended period, and that required documentation was missing. The resident herself could not recall her last shower and expressed a desire to be clean, while a family member reported persistent odors and raised concerns to staff without resolution. The Director of Nursing acknowledged the lack of documentation and stated that without completed records, there was no way to know if showers were missed or refused. The facility's policy, revised in August 2002, requires showers to promote cleanliness and observe skin condition, but this was not followed for the resident in question. The absence of documentation and follow-up resulted in the resident not receiving appropriate hygiene care, as confirmed by staff, the resident, and her family member.