Failure to Investigate and Follow Up on Resident Grievances About Bathing and Showers
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances and receive prompt resolution regarding bathing and shower services. One cognitively intact resident with multiple fractures and dependence on staff for all ADLs reported not receiving scheduled showers. A concern form documented this resident’s complaint about missed showers and indicated the complaint was only partially substantiated, with an action to monitor shower sheets and check in with the resident on shower days. However, the section for follow-up with the complainant was left blank, and the resident later stated that staff were marking shower sheets as if showers had been provided when they had not, and that no one from management had followed up with him about his grievance. Another cognitively intact resident, who required maximum assistance with toileting, bathing, and dressing, reported not receiving showers or bed baths for weeks. A concern form documented this resident’s complaint of not having had a bed bath and noted that a bath was given the following day, but again the follow-up section with the complainant was left blank. The resident stated staff told her they did not have time or would return to assist with a bath but did not come back. A friend and a family member confirmed that the resident had not been bathed for weeks and that staff repeatedly stated they would get to it but did not. A third cognitively intact resident, also requiring maximum assistance for toileting, bathing, dressing, and bed mobility, reported not receiving showers or bed baths for weeks and stated she had reported this to the DON before Christmas without any response. The facility was unable to provide any concern or grievance documentation for this resident’s report. This resident stated staff told her they did not know how to transfer her with the total body mechanical lift to the shower chair, and another staff member told her they do not provide bed baths or wash hair in bed. Facility leadership later acknowledged that nursing grievances were shared between the DON and ADON, that showers were a known problem, and that no follow-up had been done with these residents regarding their grievances, despite a written grievance policy requiring timely resolution and oversight by a grievance official.
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