Failure to Provide Scheduled Bathing and Documentation for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for bathing received baths as scheduled. According to facility policy, residents are to be bathed three times weekly and as needed, with refusals documented in the electronic medical record and on a refusal form signed by the resident, CNA, and charge nurse. Review of the resident's records over a three-month period showed that the resident received only six documented baths, with multiple scheduled bath days lacking any documentation of completion or refusal. The resident, who was severely cognitively impaired with a BIMS score of 99 and dependent on staff for bathing, reported not having received a bath in a while and was unsure of the scheduled days. Interviews with the DON and CNA confirmed that all completed baths should be documented and refusals recorded with appropriate forms. However, no additional bath sheets or refusal forms could be located for the resident, and the DON acknowledged there was no way to prove the resident was bathed more than six times in the last three months. The lack of documentation and missed scheduled baths constituted a failure to provide care and assistance with activities of daily living as required by facility policy.