Failure to Complete and Document Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs), specifically showers and bathing, were completed and properly documented for dependent residents. For one resident with diagnoses including spinal cord disease, schizophrenia, gout, and depression, records showed the individual required substantial to maximum assistance for most ADLs and was dependent for showering. However, there was no documentation of showers or bed baths for a three-month period, and the weekly skin assessments used by the facility did not indicate whether bathing had occurred, only documenting skin observations. Similarly, another resident with diagnoses such as COPD, depression, adult failure to thrive, dementia, cerebral palsy, and schizophrenia, also required substantial to maximum assistance for showering. Review of this resident's records revealed no documentation of showers over a nearly one-month period. In both cases, the DON confirmed that the facility relied on weekly skin assessments to document showers, but these assessments did not specify if showers or bed baths were completed.