Failure to Provide and Document Required Bathing Assistance
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Multiple Sclerosis, muscle weakness, seizures, lack of coordination, muscle wasting and atrophy, altered mental status, restlessness, agitation, polyosteoarthritis, and schizoaffective disorder, did not receive required assistance with bathing. The resident was assessed as needing substantial to maximal assistance for bathing, meaning staff were expected to provide more than half the effort. Despite this, documentation for a two-week period showed no evidence that bathing was completed, with staff entering a code indicating 'not applicable' for bathing on multiple consecutive days. Interviews with the resident, CNAs, the DON, and a corporate nurse confirmed that the resident did not receive a bath during this period and that the 'not applicable' code was incorrectly used in place of proper documentation. The resident reported not receiving a bath for two weeks, and staff verified that the resident required assistance for bathing. The facility used a kiosk system for documenting care, which included an option for 'not applicable,' but this was not appropriate for the resident's needs. The failure to provide and document required ADL care for bathing led to the identified deficiency.