Failure to Provide Scheduled Showers and Document Bathing Care
Penalty
Summary
The facility failed to provide scheduled showers and assistance with activities of daily living for two residents who required substantial assistance with bathing. One resident with diagnoses including intertrochanteric fracture of the right femur, cerebral palsy, and bipolar disorder was cognitively intact and care planned to receive showers twice weekly, on Tuesdays and Fridays, with the goal of having daily care needs met. From admission through discharge, this resident received only three documented showers despite the schedule, and there was no documentation in the medical record of any shower refusals. The resident’s wife reported she had raised concerns with the facility about missed showers and was told the resident had signed refusal documentation, but she stated he would not have continued to request showers if he had refused them. She further reported that the social worker attempted to convince the resident he had signed refusal paperwork, but the alleged refusal documentation could not be located. The Interim Director of Nursing later indicated that shower sheets were not used during the relevant month and that showers and refusals should have been documented in the medical record and nursing progress notes. Another cognitively intact resident with diagnoses including neuromuscular dysfunction of the bladder, benign prostatic hypertrophy, cerebrovascular accident, and anxiety disorder was also care planned to receive showers twice weekly on second shift, on Tuesdays and Fridays, with a goal of having daily care needs met. This resident reported he was supposed to receive showers on that schedule but had not had a shower in a while, stating that when he requested a shower, staff responded that they would provide one “if we can fit you in,” and that he had gone weeks without a shower. He also reported that the Director of Nursing asked if he had been refusing showers and that he refused to sign a shower sheet because he had not refused. Record review showed only one documented shower during the review period, with several shower sheets completed but no documentation of any refusals in the medical record. An LPN stated that residents should receive showers twice weekly and that refusals should be documented with a resident signature on a shower sheet and in nursing progress notes. The facility’s shower policy stated that residents would be provided showers per request or facility schedule protocols and based on resident safety.
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