Failure to Maintain Complete Bathing and Clinic Visit Documentation for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident who was totally dependent on staff for activities of daily living, including bathing, and who had multiple significant diagnoses such as dementia with agitation, hypertension, dysphagia, post-stroke hemiplegia, depression, HIV disease, cognitive communication deficit, and blindness in one eye. The resident’s Annual MDS documented that he was rarely or never understood, had severe cognitive impairment, and required total assistance for toileting, showering, footwear, and bed mobility. His care plan called for 2–3 baths weekly and as necessary, with total assistance from 1–2 staff and use of a mechanical lift with 2 staff for transfers, as well as consistent routines and caregivers due to impaired cognition. Record review of the resident’s bathing schedule for the last 30 days showed that on multiple dates (12/30/2025, 1/1/2026, 1/3/2026, 1/6/2026, 1/6/2026, 1/10/2026, and 1/13/2026), his bath did not occur or was documented as being provided 100% of the time by family and/or non-facility staff. The responsible party later stated she never gave the resident a shower and considered bathing to be the facility’s responsibility. Staff interviews revealed that a CNA had not yet given the resident a shower, and an LVN could not locate shower sheets for the resident for December, with the last available shower sheet dated 11/20/2025 and showing no skin conditions. The ADON explained that aides were expected to document showers on physical shower sheets and in the medical record, and acknowledged there were no reports of the resident refusing showers. The DON and ADON stated that showers or bed baths were being provided but not documented, and the DON attributed missing documentation to staff being busy and high staff turnover. In addition, the facility failed to maintain documentation related to the resident’s clinic visit on 12/31/2025. The resident’s medical record contained no progress notes, assessments, or uploaded documents regarding that appointment. Clinic staff confirmed that the resident had an appointment on that date and reported that he arrived “out of it” and without his health information; attempts to call the facility were unsuccessful. The responsible party also confirmed that the resident had a clinic visit on that date. The SW was unsure of the exact appointment date and stated she would request records from the clinic, but no documentation of the visit was received by the time of survey exit. These omissions occurred despite a facility policy stating that residents unable to carry out ADLs will receive necessary services to maintain grooming and hygiene, and that refusals of care should be documented after efforts to inform and educate the resident or representative.
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