Failure to Consistently Provide and Document Routine Bathing Assistance
Penalty
Summary
The facility failed to consistently provide routine baths to a resident who was dependent on staff for bathing assistance. The resident, who had a history of hemiplegia, hemiparesis, acquired absence of right foot, adult failure to thrive, and chronic obstructive pulmonary disease, was admitted with an intact cognitive status and required one-person physical assistance with bathing as per the care plan. Documentation revealed that the resident received baths on only a limited number of days over a period of more than a month, with several days marked as 'not applicable' (NA) for bathing, and no documentation of refusals by the resident. Progress notes did not indicate any refusals or reasons for missed baths, and the care plan did not specify the frequency of bathing required. Interviews with State Trained Nursing Assistants (STNAs) confirmed that 'NA' was used to indicate that a bath was not offered or provided, and sometimes also used when a resident refused a bath, without clear differentiation. The Director of Nursing (DON) stated that staff were expected to at least offer baths and document them correctly in the electronic medical record, including proper coding of refusals. The lack of consistent bathing and inadequate documentation practices led to the deficiency cited in the report.