Failure to Provide Timely Hygiene Care and Dignity to Residents
Penalty
Summary
The facility failed to treat three residents with dignity and respect by not providing timely assistance with hygiene needs, including brief changes and scheduled showers. One resident, who had severe cognitive impairment and was frequently incontinent, was not assisted with a brief change after directly requesting help from nursing staff at the nurses' station. The resident's family member arrived at the facility to find the call light still on and the resident still soiled, with nurses present at the station but not responding. Documentation showed that this resident did not receive showers on any of his preferred days throughout the month, and the care plan specifically required keeping the resident clean and dry to minimize skin exposure to moisture. Two additional residents, both with moderate cognitive impairment and requiring assistance with hygiene, also did not receive showers on their preferred days for the entire month. Both reported only receiving showers infrequently, with staff citing short staffing as the reason. Observations confirmed foul odors coming from these residents and their rooms, and both residents expressed embarrassment and frustration over their hygiene and the lack of response to their needs. Both had reported their concerns to management, but no changes were made. Interviews with staff confirmed ongoing issues with short staffing, lack of nurse participation in direct care, and failure to answer call lights in a timely manner. The ADON acknowledged that there was no effective system for tracking or documenting showers, and that nurses were not thorough in documenting refusals. Resident council meeting minutes further corroborated these issues, with multiple residents voicing concerns about not receiving showers and call lights not being answered. Observations during the survey also noted multiple call lights ringing with nurses present at the station but not responding.