Inaccurate and Incomplete Shower Documentation for Resident
Penalty
Summary
The facility failed to ensure that resident records were accurate and complete for one resident regarding documentation of activities of daily living (ADL) care, specifically showers. A review of the medication administration record (MAR) for the resident showed that nurses documented showers on multiple dates throughout the month. However, a review of the Certified Nursing Assistants' (CNA) documentation in the point of care (POC) system indicated discrepancies, including a recorded refusal on one date and showers given on two other dates, with the remaining dates marked as not applicable. Interviews with facility staff, including the unit manager, assistant director of nursing (ADON), a CNA, and an LPN, confirmed that both nurses and CNAs are responsible for documenting showers and that the POC and MAR documentation should match. The facility's policy requires that documentation in the medical record be objective, complete, and accurate. The inconsistency between the MAR and POC documentation for the resident's showers demonstrated a failure to maintain accurate and complete records in accordance with accepted professional standards.