Discussion

We identified extensive deficiencies in body cleansing, procedural steps, and water temperature for bed bathing and showering in all NHs surveyed. Suboptimal bathing was the norm. As an integral component of care, bathing is important for hygiene, comfort, confidence in appearance, ensuring healthy skin, and preventing infection. In addition, because NHs are high-risk environments for multidrug-resistant organisms (MDROs), ^{Reference McKinnell, Miller and Singh6,Reference McKinnell, Singh and Miller7} ensuring proper bathing and showering can protect residents from acquiring unwanted pathogens and reduce surface pathogens that cause disease.

Observed reasons for poor-quality bathing were multimodal, driven by both training and facility needs. Training could improve the sufficiency of applied soap. Common errors involved failure to use soap, failure to apply soap to all areas of the body, or failure to massage soap well to remove sweat, grime, and germs. Additional training-based errors included failure to bathe body parts sequentially from clean to dirty, failure to change soiled cloths, and failure to fully towel dry after showering. Bathing was only minimally improved for easily accessible areas such as the face, neck, and male genitalia compared to less accessible areas such as female genitalia, body folds, or between fingers and toes. Similarly, warm water temperature did not appreciably improve cleansing of specific body sites. Altogether, this suggests a fundamental deficiency in bathing training that must be addressed.

Facility issues were dominated by suboptimal water temperature impacting both bed baths and showers, with 9 of 10 residents complaining about being cold. Being cold markedly worsened attention to proper bathing processes and procedures, likely forcing staff to bathe quickly and causing issues with insufficient or nonexistent lather, rapid and incomplete wiping without adequate massage, and use of a single cloth for the whole bath or shower regardless of soilage or clean-to-dirty sequence. Nevertheless, there was still a 45% failure in these procedures when water temperature was adequate, suggesting a need for both improved facilities (sufficient warm/hot water to last the duration of bathing time for the entire facility) and training and education for staff performing bathing. Routine bathing and showering observations to provide feedback to NH leadership about processes and problems are likely needed for corrective response.

This study had several limitations. The study was observational and was conducted in a limited number of NHs. As an observational survey, we did not inquire about training opportunities, supply chain (eg, cloth shortages), or instructions to staff to conserve linens or reduce laundry, which, for example, could explain failure to change soiled cloths. We also conducted the study in a single region, which limits generalizability. Nevertheless, NHs varied in size and proportion of short/long-stay residents and were variably affiliated with corporations.

Overall, extensive gaps in bathing and showering existed across all NHs despite the high risk and complex care setting. High-quality bathing and showering are essential because of high MDRO prevalence and high risk of pathogen transmission in this congregate setting ^{Reference McKinnell, Miller and Singh6–Reference Murphy, Quan and Huang9} and because residents often have medical devices, wounds (eg, pressure ulcers, surgical wounds), rashes and other causes of nonintact skin. ^{Reference McKinnell, Miller and Singh6,Reference McKinnell, Singh and Miller7} Thus, bathing of NH residents cannot be assumed to be intuitive. ^{Reference Gozalo, Prakash and Mor10} It requires training, feedback, and adequate resources, particularly sufficient hot water. Dedicated and comprehensive educational efforts are needed to ensure that NH staff become skilled in bathing procedures as a critical component of high-quality NH care.