Incomplete Documentation of Resident Bathing and Care Refusals
Penalty
Summary
A deficiency was identified when a clinical record review revealed that documentation for a resident was incomplete. The resident, who had multiple rib fractures and mild protein-calorie malnutrition, was admitted to the facility and was scheduled to receive showers twice weekly. Documentation showed that the resident received showers and a full-body bath on specific dates, but there were blank entries for several PM shifts. Additionally, after the resident tested positive for Covid-19, the facility limited the use of communal showers and was expected to offer bed baths instead. However, there was no documentation in the clinical record indicating that a shower or bed bath was provided, nor any record of refusals or alternative care offered during a specific period. Interviews with facility staff, including a CNA, the ADON, and the Administrator, confirmed that the expectation was for all care provided, refusals, and alternative offers to be documented in the electronic medical record. The Administrator acknowledged that the clinical record lacked documentation of bathing care or refusals for the resident during the period in question. Facility policy required that ADL support and resident performance be documented electronically, but this was not done for the identified dates.