Incomplete Documentation of Resident Showers
Penalty
Summary
The facility failed to maintain complete and accurate documentation of showers for four residents, as required by facility policy and professional standards. Review of the facility's shower schedule and clinical records revealed missing shower documentation for all four residents on multiple scheduled dates. Specifically, shower sheets were absent for several dates for each resident, and there were no corresponding tasks identified in the Point of Care system where nursing assistants are expected to document showers. The residents involved had various medical conditions, including diabetes, hypertension, hypothyroidism, chronic respiratory failure with hypoxia, and obstructive sleep apnea. During an interview, the Director of Nursing confirmed that the clinical records for these residents did not contain complete documentation regarding showers and acknowledged that showers should be performed and documented according to the established schedule. The lack of documentation was found to be inconsistent with the facility's policy and regulatory requirements for maintaining medical records and nursing services.