Failure to Recognize and Address Repeated Shower-Schedule Complaints as Grievances
Penalty
Summary
The deficiency involves the facility’s failure to recognize and process repeated complaints about a resident’s shower schedule as formal grievances and to make prompt efforts to resolve them. A female resident with early-onset Alzheimer’s disease, severe cognitive impairment (BIMS score of 3), muscle weakness, gait and mobility abnormalities, lack of coordination, and hypertension was dependent on staff for showering and bathing. Her comprehensive care plan identified a self-care deficit and need for staff assistance with showering but did not document her shower preferences. The facility maintained a standard bathing schedule based on hall location, which placed this resident’s showers on the night shift. Over the course of about a month, the resident’s family member reported that the resident missed several showers because the aide arrived late in the evening when the resident was already ready to stay in bed, resulting in bed baths instead of showers. The family member stated the resident’s hair had not been washed in over two weeks due to receiving bed baths rather than showers. On observation, the resident’s hair appeared greasy, limp, and clumped together. The family member reported having requested multiple times that the resident’s scheduled shower time be moved to the day shift to accommodate her sleep schedule and stated these requests were made specifically to the ADON and discussed with the DON, who responded that they would try to provide day-shift showers if time allowed, otherwise the resident would continue to receive showers in the evening. Despite these repeated requests, review of the grievance logs showed no entry for a grievance from the resident’s family member. The DON acknowledged awareness of the family member’s request and stated the ADON and other staff had brought the matter to her attention on different occasions, but she did not consider it a grievance because of the facility’s standard bathing schedule and did not offer a room move to another hall to accommodate day-shift showers. The ADON confirmed the family member had requested day-shift showers more than once, stated she was unsure of the facility’s grievance process, and admitted she did not document the requests for follow-up, instead only discussing them in morning meetings. The Administrator, who was responsible for the grievance log and follow-up, indicated that if these requests had been documented as a grievance, she would have been aware and able to address the issue. The facility’s written grievance policy required that residents be allowed to voice grievances without reprisal and that the facility make prompt efforts to resolve grievances, but the policy was not followed in this case, as the family’s repeated complaints were not entered or processed as grievances.
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