Inaccurate Bathing Documentation and Recordkeeping
Penalty
Summary
The facility failed to ensure the accuracy of medical records regarding bathing for four residents reviewed for provision of showers. In several cases, there were discrepancies between the electronic health record (EHR) and the physical shower sheets or body/skin inspection forms. For example, one resident was documented in the EHR as not available for showers due to being hospitalized, yet shower sheets indicated that showers and skin assessments were completed during the same period. Another resident's EHR noted that showers were not attempted due to medical or safety concerns, while the shower sheets recorded that the resident refused showers, despite a separate area in the EHR to indicate refusals. Additionally, a resident reported that showers were not always offered according to the schedule, sometimes due to staffing issues. Other residents had similar inconsistencies, such as documentation in the EHR stating that showers were not attempted due to environmental limitations, while shower sheets indicated that showers were accepted on those dates. These discrepancies were identified during a complaint investigation and were confirmed through interviews with the Director of Nursing, who acknowledged the inconsistencies and the need for staff education on proper documentation. The affected residents had complex medical and psychiatric diagnoses and were dependent on staff for bathing and other activities of daily living.