F0677

E

Failure to Provide and Coordinate Scheduled Bathing and Hygiene Assistance

Fort Belvoir, Virginia Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

Facility staff failed to provide necessary activities of daily living (ADL) assistance, specifically bathing and hair washing, to multiple dependent residents. One resident with a history of repeated falls and unsteadiness on feet was cognitively intact and had a care plan emphasizing her preference and goal to increase functional ability with bathing, including choosing between a tub bath, shower, bed bath, or sponge bath. She reported that staff were relying on her to ask for showers, that she believed she had designated shower days, and that she had instead been taking basin baths and using washcloths to run through her hair. ADL records showed scheduled showers twice weekly, but documentation reflected self-bathing on one date and "NA" on another, and the ADON later acknowledged that showers were not documented for this resident and that her preference for daytime showers had not been aligned with the existing schedule.

Another resident admitted with a right intertrochanteric femur fracture, and diagnoses including repeated falls and unsteadiness on feet, reported that he received his first shower on the morning of the survey interview, stating that it was the first thorough washing since admission. He stated that staff had not bathed him in the shower room or in bed prior to that day, although he had been able to perform limited self-care such as shaving, wiping himself with a washcloth, and brushing his teeth. Staff interviews indicated that showers or refusals were to be documented in the electronic record, that there was a set shower schedule, and that shower days should be posted on room boards and in CNA computers. The resident’s room board did not list shower days, although an LPN confirmed that the resident was scheduled for showers twice weekly on the day shift. ADL documentation showed the first recorded shower on a date consistent with the resident’s report and an earlier scheduled date marked as "NA."

A third resident with Alzheimer’s dementia and paroxysmal atrial fibrillation, who was severely cognitively impaired and dependent or requiring substantial assistance for most self-care tasks including showering/bathing, was observed on two separate days with oily, flat hair, dry rough skin on the face, and later with an offensive odor. Her care plan included a goal to increase functional ability with bathing and interventions allowing her to choose the type of bath while requiring substantial/maximal assistance. A family member reported that her hair had not been washed for weeks and that he planned to ensure her hair was washed before transfer to another facility. Bathing records showed refusals of showers/tub baths on two dates, with no documentation of alternative bathing or hair washing.

A fourth resident, cognitively intact but requiring substantial/maximal assistance with showering/bathing and several other ADLs, had a care plan goal to increase functional ability with bathing and interventions emphasizing her choice of bathing method. She was observed with multiple scabs on her arms and legs, dry and scaly skin on her arms, legs, and face, and hair that had been washed and set at the beauty shop that day. She stated she was not taking showers or tub baths because hospital staff had told her she could not immerse in water due to dressings, and she reported that no one at the facility had informed her that bandages could be removed and reapplied to allow bathing. CNA interview indicated that every resident received showers or tub baths as scheduled, and documentation stated that this resident was receiving showers or tub baths according to her schedule, but the resident’s own account and the DON’s subsequent interview confirmed that she had not been receiving showers or tub baths at the facility due to her understanding of the hospital’s instructions and lack of education from facility staff.