Inaccurate EMR Documentation of Resident Bathing and Shower Refusals
Penalty
Summary
The facility failed to ensure complete and accurate medical record documentation for a resident whose bathing care was not properly recorded in the electronic medical record (EMR). The resident, admitted in 2022 with type 2 diabetes, right-sided hemiplegia/hemiparesis, and generalized muscle weakness, was scheduled to receive showers on Sunday and Wednesday during the PM shift. Review of the EMR bathing record for the month of January showed that "response not required" was documented for all shifts except for three entries: one notation of "resident not available" and two entries indicating bed baths on specific dates. This documentation did not align with the facility’s shower schedule or with staff reports of the resident’s actual bathing routine. Interviews with the resident and multiple CNAs revealed that the resident routinely refused showers and preferred bed baths, which staff reported were being provided, often on the morning shift instead of the scheduled PM shift. CNAs stated that they were responsible for completing shower sheets, obtaining nurse signatures, and documenting showers, bed baths, and refusals in the resident’s chart. They also stated that when a resident refused a scheduled shower, they would notify a licensed nurse and offer the shower multiple times during the shift, then document the refusal. However, review of the EMR showed that CNAs frequently used the code "response not required" instead of documenting refusals or accurately recording when bed baths were provided. Licensed nurses and facility leadership, including the Director of Staff Development and the Director of Nursing, confirmed that the EMR documentation for the resident’s showers and bed baths in January was inconsistent with expectations and the facility’s shower schedule. The DSD verified that only two bed baths were documented for the month, whereas at least eight showers should have been documented if the resident was receiving bathing twice weekly as scheduled. Both the DSD and DON stated that staff were expected to use correct coding, such as documenting refusals and appropriate reasons when showers did not occur, and confirmed that the existing charting did not meet these expectations. Review of the facility’s bath/shower policy indicated that staff were required to document the date and time of showers/tub baths and, if refused, the reasons and interventions taken, which was not consistently done for this resident.
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