Failure to Care Plan for Shower Refusals and Discharge Needs
Penalty
Summary
Surveyors identified a deficiency in care planning related to a cognitively intact resident admitted with malignant neoplasm of the skin. The resident’s Minimum Data Set (MDS) showed a BIMS score of 15, indicating intact mental status, with clear speech and ability to understand and be understood. The resident reported during interview that he had not showered for some time and that he sometimes refused showers. Review of the shower record from 2/10/26 to 3/11/26 showed the resident had not received a shower for more than a month, despite being scheduled for showers twice weekly. The ADL care plan did not address the resident’s ongoing refusal to shower, and the DON acknowledged that the facility’s expectation was that the care plan be updated with the refusal and appropriate interventions. This was inconsistent with the facility’s “Shower for Residents” policy, which required that continual refusal to shower/bathe trigger social services involvement and care plan interventions to remedy the situation. Surveyors also found that the Interdisciplinary Team (IDT) did not develop a care plan addressing the resident’s discharge plan upon admission. Although the MDS indicated no discharge plan, care plan conference documentation on multiple dates reflected that the resident had discharge potential. The DON was unable to provide a discharge care plan for the resident and stated that discharge planning was addressed during care conferences rather than through a written care plan initiated on admission. Additionally, care plan conference records showed that the resident’s family member was not invited to participate, and the DON confirmed that the family member was not consistently invited. These findings were not in accordance with the facility’s Care Planning policy, which required that all resident care needs be identified through continuous assessments and care planned with measurable objectives and adequate interventions, and with the facility’s Care Planning-IDT process that included the resident and family/representative whenever possible.
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