Failure to Accurately Document Resident Showers in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident, specifically regarding the documentation of showers provided or refused. Record reviews showed that the resident, who was admitted with multiple medical conditions including osteopenia, right hip arthroplasty, and a left femoral neck fracture, required substantial assistance with activities of daily living (ADLs) such as bathing. The care plan indicated the resident was at risk for pressure ulcers and required regular hygiene to maintain dignity and prevent complications. Despite the established schedule for showers and the use of shower sheets for documentation, two shower sheets were missing for days when the resident either received or refused a shower. Interviews with the DON, Administrator, and CNAs confirmed that showers or refusals were expected to be documented on the shower sheets, but staff could not account for the missing documentation. The facility's own policy required nursing staff to record care and treatment, including showers, in accordance with regulatory requirements. The lack of documentation was acknowledged by multiple staff members, including the DON, Administrator, and CNAs, who stated that it was their responsibility to ensure showers and refusals were properly recorded. The absence of these records resulted in incomplete and potentially inaccurate medical records for the resident, as required by professional standards and facility policy.