Incomplete Documentation of Missed or Refused Showers in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents regarding their showers and bathing, as required by accepted professional standards. For one resident, documentation in the electronic medical record (EMR) did not include nurse notes about missed or refused showers, despite the care plan and point of care (POC) system indicating multiple missed or refused showers. Interviews with staff revealed that certified nursing assistants (CNAs) reported refusals to charge nurses and documented them in the POC, but this information was not consistently reflected in nurse notes. The resident and their responsible party both reported concerns and complaints about missed showers, with the resident stating he did not refuse showers and had requested them daily, but was only showered on two occasions during the review period. Another resident also had incomplete documentation regarding showers and bathing. The POC reflected several refusals and missed showers, but nurse notes did not document these events for extended periods. The resident reported missing multiple showers and expressed frustration, while family members had also complained. Staff interviews confirmed that refusals were documented in the POC and reported to charge nurses, but this was not consistently followed up with documentation in nurse notes. Nursing staff, including the wound nurse and acting DON, acknowledged that nurse notes should reflect refusals or missed showers, especially when they occur over an extended period, but could not explain the lack of documentation. The facility's documentation policy required complete and accurate documentation for each resident on all appropriate clinical record sheets. However, the review found that nurse notes did not consistently record missed or refused showers for the two residents, despite evidence from other sources and staff interviews that such events occurred. The administrator and nursing management were not aware of the documentation gaps until informed by surveyors, and there was no explanation provided for the missing entries in the clinical records.