Failure to Implement QAPI Monitoring for Scheduled Showers
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor its QAPI and QAA processes to ensure residents received scheduled showers and that refusals were properly documented. A Quality Improvement Corrective Action Plan dated 01/12/2026 identified that residents were not receiving showers consistent with their schedules and outlined actions such as CNAs notifying the floor nurse of refusals and submitting shower sheets for review. However, the plan’s objective measures for evaluating effectiveness were incomplete, and there was no sufficient evidence of ongoing monitoring or evaluation to ensure corrective actions were carried out. A cognitively intact resident with hemiplegia and cerebral infarction, who required substantial/maximal assistance for showering, was scheduled for showers three times weekly but had multiple dates on his Bath/Shower Log left blank, with no documentation of showers given or refusals. Nurse’s notes contained no entries indicating shower refusals. During observation, the resident’s hair appeared oily with white flakes, and he reported that he was supposed to receive showers three times a week but often only received one. CNAs and supervisory staff confirmed that on several dates no shower aide was assigned, the resident did not receive showers, and shower logs were not completed as required. The DON and other staff acknowledged that residents not receiving showers had been identified as an issue and that the QAPI corrective actions related to showers were not being implemented.
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