Failure to Maintain Accurate Shower Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed for shower documentation. Specifically, there were no shower sheets filled out for the resident over two separate periods totaling twelve days, and the electronic medical record corroborated the absence of documentation. There was also no indication in the records that the resident refused showers during these periods. The facility's process for tracking showers involved maintaining shower sheets in a large binder, but this system did not ensure that all showers or refusals were consistently documented. The resident involved was an elderly female with severe cognitive impairment, a history of nontraumatic subarachnoid hemorrhage, anxiety disorder, unspecified dementia, hypokalemia, and lack of coordination. She required partial assistance with bathing. Interviews with staff, including the DON and a CNA, confirmed the expectation that residents receive showers three times a week and that refusals are to be documented. However, the lack of documentation for the specified periods was acknowledged by both the DON and the Administrator, who also failed to provide the facility's shower/bathing policy when requested.