F0677

D

Failure to Provide and Document Scheduled Bathing and ADL Care for Three Dependent Residents

Fort Oglethorpe, Georgia Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and document scheduled bathing and related ADLs for three dependent residents, despite a policy requiring CNAs and nurses to document ADL care at the point of care and for nurses to review ADL documentation daily. The facility’s policy states that ADLs must be tracked daily in the EHR or CNA ADL flow sheet and that nurses should not accept illegible documentation. For one resident with hemiplegia, morbid obesity, CHF, diabetes, muscle weakness, difficulty walking, and abnormal posture, the MDS showed the resident was cognitively intact and required substantial to maximal assistance with bathing and other ADLs, and the care plan called for showers or baths on scheduled days and as needed, with daily hygiene care. However, review of bathing sheets over several weeks showed only eight documented showers or bed baths, fewer than the three scheduled showers per week, with no documentation of refusals in either the bathing records or progress notes.

Interviews with this resident revealed she understood she was supposed to receive showers three times per week and reported she had not received a shower that week and generally only received one shower per week. She stated she had never refused showers and wanted showers or bed baths three times per week as scheduled. CNAs interviewed stated residents typically receive showers three times per week, that refusals should be documented after multiple attempts, and that this resident did not refuse showers. An LPN confirmed the resident’s shower schedule, acknowledged that she did not consistently receive showers or bed baths, and, after reviewing the shower sheets, stated it appeared the resident had not been consistently asked to shower. The LPN and the LPN Unit Manager both stated that if care or refusals were not documented, it meant it was not done, and the Unit Manager acknowledged she had not been verifying showers daily, citing being busy.

For a second resident with peripheral vascular disease, gait abnormalities, a left below-knee amputation, phantom limb pain, legal blindness, and a need for assistance with personal care, the MDS showed the resident was cognitively intact, and the care plan included providing showers or baths on scheduled days and as needed. Review of bathing sheets over about a month showed bathing documented on 14 dates, but only six baths were actually received, fewer than the three scheduled showers per week, with only one documented refusal due to cold water. The LPN Unit Manager confirmed, based on the point-of-care history, that the resident did not receive scheduled bathing and reiterated that if it was not charted, it was not done. During observation and interview, this resident, found lying in bed disheveled, stated she was not refusing to bathe and that staff were simply lazy, and confirmed she wanted the baths.

For a third resident with unspecified dementia, white matter disease, gait abnormalities, need for assistance with personal care, and bilateral artificial hip joints, the MDS indicated severe cognitive impairment. The care plan identified risk for ADL decline related to impaired mobility and dementia, with goals that ADL needs be met and interventions including providing showers per schedule and setting up the resident for ADLs. Review of bathing sheets over a similar period showed bathing documented on 14 dates, but only five baths were received, again fewer than the three scheduled showers per week, with only one documented refusal. A family representative reported having requested staff three or four times over two weeks to wash the resident’s hair during bathing. A CNA described ADLs as including washing hair, shaving, bathing the body, and cutting nails, and, on observation, confirmed the resident’s hair appeared greasy while the resident was lying in bed. The Administrator confirmed that everyone should be receiving showers and that there were no excuses for not doing so.