Failure to Provide Scheduled Bathing and Document Care Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically scheduled bathing, to a resident who was dependent on staff for showering. The resident was admitted with generalized muscle weakness and had an ADL care plan initiated that identified self-care performance deficits related to weakness, pain, and impaired mobility. The care plan and facility task schedule specified that the resident was to receive two baths/showers per week, on Tuesdays and Saturdays. A quarterly MDS assessment documented that the resident had moderately impaired cognition, was dependent on staff for showering/bathing, and that showering/bathing was very important to them. In an interview, the resident reported not receiving baths/showers consistently and stated it had been three weeks since their last shower. Record review of the Kardex and the facility’s electronic health record showed multiple missed showers between early December and early March on numerous scheduled dates, despite the established twice-weekly bathing schedule. The records also showed only two documented refusals of showers on two specific dates, while the DON later stated the resident had refused bath/shower multiple times without documentation. The Resident Care Manager and the DON both stated that staff were expected to provide showers/baths as scheduled and, when residents refused care, to offer it at another time, document the refusal, and report it. The documented pattern of missed showers, combined with incomplete documentation of refusals, demonstrated that the facility did not consistently follow the resident’s care plan and bathing schedule as required by policy and regulation.
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