Failure to Document ADL Care and Refusals in Resident Records
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for a resident who required assistance with activities of daily living (ADLs), specifically regarding documentation of baths, showers, hair care, and refusals of care. The resident, who had multiple diagnoses including cognitive communication deficit, muscle wasting, Parkinson's disease, diabetes, dementia, and major depressive disorder, was dependent on staff for personal hygiene and bathing. The care plan indicated the need for extensive assistance with bathing or showering at least three times weekly, and interventions were in place to notify a family member in case of refusals. However, there was no intervention specific to hair care refusals or documentation. Record reviews revealed multiple dates with missing documentation for both personal hygiene and bath/shower care, as well as a lack of documentation regarding hair care and refusals. Comprehensive CNA Shower Review sheets also lacked entries for hair washing on several dates. Nurse progress notes did not include any documentation of refusals for baths, showers, or hair care. Interviews with staff confirmed that the resident often refused showers and hair care, but these refusals were not consistently documented, and staff sometimes failed to notify the charge nurse as required by facility policy. The facility's policy required all services provided, progress toward care plan goals, and any changes in the resident's condition to be documented in the medical record, including refusals and notifications to family or physicians. Despite this, staff interviews and record reviews confirmed that documentation was incomplete or missing for several scheduled care events, and refusals were not properly recorded or communicated, resulting in a failure to maintain clinical records in accordance with accepted professional standards.