Inaccurate Bathing Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents regarding their scheduled bathing care. Certified Nurse Aide (CNA) C documented in the medical records that both residents received a bath on a specific date, when in fact, neither resident received the care as scheduled. This was confirmed through interviews with the residents, who reported not receiving their showers due to ongoing water issues in the facility, such as low water pressure and lack of hot water. Both residents were scheduled for showers three times weekly and required staff assistance, as indicated in their care plans and nurse aide task records. Further investigation revealed that CNA F, who worked on the relevant date, acknowledged that only three out of five scheduled residents received their baths, and that she had mistakenly documented that the two residents in question had received their showers. The residents themselves confirmed during interviews that they did not receive their scheduled showers, and one resident noted that his family was concerned about missed showers. The facility's shower schedule and care plans corroborated the residents' accounts and the CNA's admission of documentation errors. Interviews with facility leadership, including the Director of Nursing (DON) and the Administrator, confirmed that the expectation is for nurse aides to accurately document care provided, and to notify nursing staff if a resident refuses care. Both leaders stated that documenting care as provided when it was not is considered falsification of records. The facility's policy on charting and documentation requires that records be objective, complete, and accurate, which was not followed in these instances.