Incomplete Documentation of Resident Bathing Records
Penalty
Summary
The facility failed to ensure that residents' clinical records were complete and accurately documented for two of nine residents reviewed. For one resident, a quarterly MDS assessment indicated cognitive intactness and a need for supervision with showering, with a care plan specifying showers twice a week and honoring refusals. The facility's shower schedule aligned with this plan, but bathing records for specific dates showed no documentation that a shower or bath was provided or refused. Despite this, the resident reported receiving showers as expected. For another resident, the quarterly MDS assessment showed moderate cognitive impairment and independence with showering, with a care plan to follow the shower schedule and honor refusals. The shower schedule indicated weekly showers, but bathing records for certain weeks lacked documentation of showers provided or refused. The resident confirmed that their preferences were honored and showers were received as desired. The DON acknowledged that showers were provided according to preferences, but documentation was missing for the identified dates.