Failure to Accurately Document Resident ADL Care
Penalty
Summary
The facility failed to maintain accurate and complete documentation in the medical record of a resident regarding activities of daily living (ADLs), specifically related to showers and bed baths. During the resident's stay, only 6 out of 12 possible showers or bed baths were documented, with records showing 4 completed and 2 refused. There was no documentation for the remaining 6 instances, making it unclear whether the resident received or refused care on those occasions. This lack of documentation was identified after concerns were raised by the resident's family member about whether the resident was receiving appropriate hygiene care and skin checks. Further review revealed a late entry progress note written by a nurse after a family meeting, stating that the resident received a bed bath on one date and refused care on another. However, there were no supporting shower sheets or other documentation to verify these claims. When questioned, the Nursing Home Administrator could not explain where the information in the late entry note originated, as it was not supported by existing records. The facility's own policy requires that documentation be completed at the time of service or by the end of the shift, but this standard was not met in this case.