Incomplete Documentation of Deep Cleaning for Resident on Isolation Precautions
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurately documented after performing a deep clean of the resident's room. The resident, who had diagnoses including chronic kidney disease, muscle weakness, and hyperlipidemia, was placed on contact isolation precautions. Housekeeping staff began deep cleaning rooms in response to rash incidents, with the process involving disinfecting hard-to-reach areas such as beds and curtains. Although a designated Deep Clean Checkoff List for isolation rooms existed, it was not completed for this resident's room. Interviews with housekeeping staff and the Housekeeping Supervisor confirmed that deep cleaning was performed, but no checklist or documentation was completed to verify the specific actions taken. The resident confirmed that her room had been deep cleaned while she was showering. The Director of Nursing stated that accurate and timely documentation is necessary to confirm completed actions and to inform subsequent shifts. Review of facility policy indicated that documentation in the medical record should be objective, complete, and accurate, but this was not followed in this instance.