Failure to Accurately Document Resident Bathing Activities
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's bathing activities, as required by accepted professional standards. A review of the clinical record for a resident with hemiplegia and hemiparesis following a cerebral infarction revealed that the resident was totally dependent on staff for bathing. The resident's care plan specified scheduled bath days, but the bath flowsheet showed missing documentation for three scheduled days. On one of these days, the assigned CNA confirmed the resident refused the bath but acknowledged she did not document the refusal. On the other two days, the responsible CNA stated she provided the baths but failed to document them. Interviews with the CNAs and the Director of Nursing confirmed that the baths or refusals were not recorded as required. The lack of documentation was verified by staff upon review of the bath flowsheet, and staff acknowledged that all baths given or refused should have been documented. The deficiency was identified through record review and staff interviews, which established that the facility did not maintain complete and accurate records of the resident's ADL care.