Failure to Accurately Document Resident Bathing and Refusals
Penalty
Summary
The facility failed to ensure that medical records for a resident were maintained in accordance with professional standards and were complete and accurately documented. Specifically, for one resident with diagnoses including schizoaffective disorder, anxiety disorder, and hypertension, there was a lack of documentation regarding whether scheduled baths or showers were provided or refused on nine occasions over a one-month period. The resident's care plan and shower schedule indicated a need for assistance with personal hygiene and specified bathing days, but the electronic clinical record did not reflect whether the resident was bathed or had refused on those dates. Additionally, there were no corresponding notations in the nurses' notes to indicate refusals. Interviews with the Regional Compliance Nurse confirmed that the CNAs responsible for bathing the resident on the missing documentation dates reported that the resident had refused on several occasions, but these refusals were not documented in the clinical record or nurses' notes as required by facility policy. The resident herself recalled refusing some showers but could not specify which days. The facility's documentation policy requires prompt and complete documentation of care or treatment, but this was not followed in the case of the resident's bathing records.