Failure to Provide and Document Assisted Bathing and Shower Care for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assistance with activities of daily living (ADLs), specifically bathing and showers, for a resident who was dependent on staff for this care. The resident was admitted for rehabilitation following an acute hospitalization with diagnoses including bilateral lower extremity DVT, status post IVC filter placement, an unstable T9 fracture, back pain, and weakness. The admission assessment documented that the resident was cognitively intact with a BIMS score of 15 and required extensive assistance for dressing, toileting, and personal hygiene, and was totally dependent on staff for bathing with one-person physical assist. The care plan identified an ADL self-care performance deficit related to deconditioning and weakness, with an intervention that the resident required maximum assistance of one with bathing. Review of the electronic medical record, including GNA task documentation, TARs, and progress notes, showed multiple missed or refused showers that were not properly documented or followed up. In August, September, and October, the resident had physician orders for showers twice weekly on the day shift, with instructions to document all refusals with a progress note. Documentation showed the resident did not receive scheduled showers on multiple dates and was marked as refusing showers on several others. However, progress notes were either missing or incomplete for many of these refusals, and there was no documentation explaining why the resident refused showers on the majority of the dates indicated. Further review revealed that the facility did not follow the physician’s order to document all shower refusals in progress notes and did not document any notification to the physician regarding the resident’s frequent refusals. The resident’s ADL care plan was not updated to reflect the pattern of frequent shower refusals, and there were no measurable goals or interventions added to address the resident’s bathing needs and preferences in light of these refusals. Additionally, there was no documentation that the resident’s representative had been informed of the frequent refusal of showers. During an interview, the DON acknowledged that the resident never or rarely took a shower and believed this was documented, but no additional documentation was provided by the time of survey exit.
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