Failure to Implement and Document ADL Care Plan for Resident Showering by Family
Penalty
Summary
The deficiency involves the facility’s failure to implement and update a complete, individualized ADL care plan and corresponding interventions for a resident whose wife was providing showers. Facility policy titled "Quality of Life" required development and implementation of care plans and interventions to maintain, improve, or prevent avoidable decline in ADLs based on assessed needs, goals, and preferences. The resident was admitted with moderate cognitive impairment and required assistance with ADLs. The 5‑day admission MDS documented these needs, and the ADL care plan initiated the day before the MDS specified that one staff member would provide bathing/showering assistance as needed. However, the care plan did not document the resident’s or wife’s preference for the wife to provide showers. Progress notes documented that the wife would do the resident’s laundry and would be present in the evenings to shower him on his shower days. The resident later stated that while he was in the facility, staff did not shower him and that his wife assisted him instead. An LPN and the Residential Care Manager/RN both reported that the wife was insistent on showering the resident and did not want staff involved, and the RN acknowledged there was no documentation of any orientation to the shower room for the wife. The RN also acknowledged a fall risk associated with family members showering residents. The Administrator stated she learned after the fact that the wife had been showering the resident, that this was not sanctioned by the facility, and that an assessment to verify safety with showering, which should have been completed, was not done for this resident.
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