Failure to Accurately Document Resident Bathing in ADL Records
Penalty
Summary
Nursing staff failed to maintain accurate and complete documentation of a resident's activities of daily living (ADL), specifically regarding bathing. The resident, who was dependent on staff for bathing and preferred daily bed baths, was scheduled to receive a bath Monday through Saturday according to the CNA assignment sheet. However, review of the ADL flowsheet revealed missing documentation for three specific dates, and there was no evidence in the nurses' notes that the resident refused baths on those days. Interviews with the assigned CNAs confirmed that bed baths were provided on the dates in question, but the staff admitted they did not document these baths as required. Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) reviewed the records and confirmed the lack of documentation for the resident's baths on the specified dates, acknowledging that the records were not maintained in accordance with accepted professional standards.