The facility failed to honor resident choice and self-determination regarding bathing by not consistently providing showers as expected and as important to residents. Several cognitively intact and impaired residents with significant ADL needs, incontinence, and mobility limitations reported going one to two weeks or longer between showers, despite stating they wanted and were supposed to receive two showers per week. Documentation showed prolonged gaps between showers without recorded refusals, while staff acknowledged ongoing problems with shower provision, short staffing, unclear assignment of shower responsibilities, and confusion over whether to document showers on paper or in the EMR. Leadership confirmed that showers should be offered twice weekly and that lack of documentation or "not applicable" entries meant showers were not given, yet the DON had not been reviewing shower records, resulting in residents feeling dirty, embarrassed, neglected, and concerned about body odor.
Failure to Honor Resident Shower Preferences: The facility did not honor shower preferences for three residents with significant care needs, including dementia, COPD, a catheter, and severe cognitive impairment. Shower records showed limited bathing, while progress notes did not document showers or refusals. One resident reported feeling dirty and wanting showers twice weekly, another appeared with oily hair and body odor, and a responsible party reported an unshaved resident with long toenails, poor oral care, and soiled clothing. The DON and Administrator said residents should be kept clean and preferences should be honored, but were unaware the residents were not receiving showers twice per week.
Failure to honor resident shower preferences and document refusals: two cognitively intact residents who needed bathing assistance were not shown to have received showers at the expected frequency, and care plans did not address bathing preferences. CNA shower review sheets and nurses' notes lacked documentation of showers or refusals, while CNA, LPN, DON, and the Administrator all stated residents should be offered showers at least twice weekly and refusals should be recorded.
The facility failed to honor a resident’s right to self-determination by not adequately promoting and facilitating resident choice, resulting in a repeated citation related to resident rights. The deficiency is linked to a prior uncorrected event and a subsequent complaint investigation, though no further clinical or resident-specific details are provided in the report excerpt.
A resident with a supra pubic catheter repeatedly requested to have their urinary collection bag changed from a leg bag to a bedside gravity drainage bag at night, but staff did not honor this request. The care plan and physician's orders did not specify the resident's preferences or address the use of different collection bags, resulting in the resident experiencing urinary leakage, a saturated bed, and distress. Nursing staff and leadership acknowledged the oversight, and observations confirmed the resident's needs were not met.
The facility did not consistently honor resident shower preferences or provide showers according to the stated schedule, resulting in several residents—many with significant physical impairments—going extended periods without showers or adequate hygiene. Documentation was incomplete, care plans often lacked individualized shower preferences, and staff cited insufficient staffing as a barrier to meeting resident needs.
The facility did not provide timely showers in accordance with resident preferences and care plans, resulting in several residents experiencing long gaps between showers and expressing dissatisfaction with their hygiene. Staff interviews revealed that showers were often missed due to staffing shortages and lack of a dedicated shower aide, and documentation of bathing and skin assessments was incomplete or missing.
A CNA failed to honor a resident's right to refuse getting out of bed for a shower, proceeding with a transfer despite the resident's objections. The resident, who was able to communicate their wishes, sustained a significant skin tear during the transfer, requiring hospital treatment. The incident revealed that staff did not consistently respect or understand resident rights, and the facility's investigation focused on transfer technique rather than the violation of self-determination.
Three residents who required assistance with bathing did not consistently receive showers according to their care plans and preferences, often going extended periods without bathing. Residents reported feeling dirty and uncomfortable, and staff interviews confirmed that staffing shortages and turnover led to missed showers, with management aware of the ongoing concerns.
A resident with intact cognition and independent ADLs, who had multiple chronic conditions, requested transfer to another LTC facility to live closer to a special-needs child. Although an initial referral was reportedly sent by social services, there was no documentation in nursing or social service notes or in the care plan reflecting the resident’s wish to transfer, no recorded follow-up, and no documented communication back to the resident. The SSD and Administrator could not provide records of ongoing efforts, beyond a single text and an undated initial referral, while the receiving facility’s admissions nurse reported repeatedly requesting updated nursing notes and stating the original referral had expired after 30 days and needed to be resubmitted. This resulted in months of inaction on the resident’s transfer request and failure to support the resident’s right to self-determination.
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