Failure to Document Scheduled Baths in Resident Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate by not documenting the provision of scheduled baths. According to the facility's policy, documentation and charting are required to provide a complete account of resident care. Review of one resident's clinical record showed that the resident, who was dependent on staff for bathing and had multiple diagnoses including polyneuropathy, type 2 diabetes mellitus, morbid obesity, chronic congestive heart failure, and cardiomegaly, was scheduled to receive baths on specific days. However, there was no documentation indicating that baths were provided on several scheduled dates. Interviews with the CNA assigned to the resident confirmed that the baths were provided on the scheduled days, but the CNA acknowledged that these were not documented in the resident's bath documentation. The Chief Nursing Officer also confirmed that if a bath was provided, it should have been documented. The lack of documentation resulted in an incomplete and inaccurate medical record for the resident.