Failure to Accurately Document Resident Hygiene Preferences and ADL Care
Penalty
Summary
The facility failed to ensure accurate and consistent documentation of a resident's personal hygiene preferences and the completion of activities of daily living (ADL) care. Specifically, for one resident, there were discrepancies between the paper shower log and the electronic health record (EHR) regarding who performed and documented bed baths on two separate dates. The paper shower log indicated that a Geriatric Nursing Assistant (GNA) provided the care, while the EHR showed that an LPN and a different GNA documented the same tasks. The staff member who performed the care did not document in the EHR, and another staff member documented on their behalf without confirming the resident's preferences or whether a shower was offered and refused. Interviews with staff revealed that the GNA responsible for providing the bed baths only documented in the paper shower log and did not use the EHR for any residents. The LPN confirmed that she documented in the EHR when the person who completed the task had not done so, rather than ensuring the actual caregiver completed the documentation. The Director of Nursing acknowledged the mismatch in documentation and was unable to confirm if the resident's hygiene care was based on their preferences or if refusals were properly recorded.