Inaccurate Bathing Documentation and Falsified Signatures for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete documentation of bathing and hygiene care for two cognitively intact residents, contrary to its charting and documentation policy. One resident, admitted with chronic respiratory failure with hypoxia, muscle weakness, and needing assistance with personal care, used a wheelchair and was dependent on staff for bathing and showers per the care plan. The census showed this resident was hospitalized on a date in October and did not return until several days later, yet the shower record indicated a shower was provided during the hospitalization, which the DON confirmed could not have occurred. Shower records from mid-October through early January showed scheduled showers documented as completed, while the resident reported having begged for a bath for three days, stated there was no hot water, and that she only received one shower a month. A shower sheet dated early January showed a bed bath with a CNA’s signature that did not match the CNA’s prior signature; the CNA later confirmed by phone that she did not have that resident assigned that day and did not sign the sheet. The scheduler confirmed a different CNA had the resident that day, and that CNA confirmed she did not provide or document the scheduled bath or shower and did not know why it was not offered. The second resident, admitted with systemic lupus erythematosus, cerebral palsy, muscle weakness, and a need for assistance with personal care, used a wheelchair and required substantial to maximal assistance for bathing and showering. The care plan included providing a sponge bath when a full bath or shower could not be tolerated. This resident reported not having a shower in three weeks and attributed the lack of bathing to hot water issues on the unit; observation showed the resident’s hair was very oily, and the resident expressed feeling “disgusting.” Shower records indicated that showers were refused on two dates in January, with both sheets signed by the same CNA and an illegible nurse signature. During an interview and review of the shower sheets, the CNA stated the resident never refused showers on those dates, became upset, and asserted that the signatures on those sheets were not hers, pointing to an earlier shower sheet where her authentic signature appeared and looked different. An LPN confirmed the questioned signatures did not resemble the earlier signature, and the DON confirmed that no staff member should sign for a CNA other than the CNA providing the care. The facility’s policy required documentation in the medical record to be objective, complete, and accurate, which was not followed in these instances.
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