F0842

E

Failure to Accurately Document Ordered Baths/Showers in Clinical Records

Baton Rouge, Louisiana Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate clinical records for three residents regarding ordered baths/showers, contrary to its own documentation policy and accepted professional standards. The facility’s policy, revised in October 2025, requires documentation every shift for skilled residents and for ADL assistance by CNAs, with records accurately reflecting nursing care and ADL assistance. For Resident #1, physician orders specified baths on Tuesday, Thursday, and Saturday during daytime hours, but the bath log from 12/11/2025 through 01/06/2026 showed no documentation of a bath or shower on multiple ordered dates, including 12/13/2025, 12/16/2025, 12/23/2025, 12/25/2025, and 01/06/2026. A CNA later confirmed that baths were provided on at least two of those dates but were not documented.

For Resident #2, physician orders also required baths on Tuesday, Thursday, and Saturday during night hours, yet the bath log from 11/02/2025 through 01/03/2026 contained no documentation of baths or showers on numerous ordered dates. The CNA who worked with this resident on several of the missing dates recalled giving a shower on one of those dates but was unsure if it had been documented, and acknowledged that such care should be recorded. For Resident #3, with similar physician orders for daytime baths on Tuesday, Thursday, and Saturday, the bath log from 11/01/2025 through 01/07/2026 lacked documentation of baths or showers on several ordered dates. The CNA assigned on one of those dates could not remember if the bath was given and confirmed that she did not document it, though she should have. The DON verified that there was no documentation of completed baths or showers for these residents on the identified dates, despite the requirement that such care be recorded.