Failure to Accurately Document Bathing Care in Resident Medical Records
Penalty
Summary
The facility failed to ensure that medical records were maintained in accordance with accepted professional standards and practices, specifically regarding the documentation of bathing or showering for four residents. For each of these residents, there were multiple instances over a one-month period where it was not documented whether a bath or shower was given or refused, despite scheduled bathing days and care plans indicating the need for 2-3 showers per week. The lack of documentation was identified through review of electronic clinical records, care plans, shower schedules, and nurses' notes, which did not reflect either the provision of care or resident refusals on numerous scheduled days. Resident records reviewed included individuals with significant medical conditions such as heart failure, stroke, hemiparesis, hemiplegia, high blood pressure, memory deficits, vascular dementia, morbid obesity, cognitive communication deficits, atrial fibrillation, kidney failure, lymphedema, and muscle wasting. These residents were all dependent on staff for bathing or showering, as indicated by their care plans and Minimum Data Set (MDS) assessments. Despite this dependency, the documentation in the electronic clinical record was incomplete, with several scheduled bathing days lacking any record of care provided or refusals, and no corresponding notes in the nursing progress records. Interviews with the DON revealed that, upon inquiry, CNAs reported having provided baths or showers or having received refusals from residents on the undocumented days. However, these actions or refusals were not entered into the electronic Point of Care Tasks or nursing notes as required by facility policy. The administrator confirmed that the absence of such documentation resulted in inaccurate medical records. The facility's policy, revised in January 2023, requires that a medical record be maintained for every resident, including documentation of services provided, in accordance with professional standards.