Incomplete EMR Documentation of ADL-Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for residents’ ADL-bathing in accordance with its own charting and documentation policy. For four residents reviewed, the electronic medical record (EMR) 30‑day task records for ADL-bathing did not contain entries indicating that a bath was provided or refused on certain scheduled bath days, despite established bathing preferences. The facility’s policy requires that each resident’s medical record contain an accurate representation of the resident’s experiences, with complete, accurate, and timely documentation of services provided, including care such as bathing, to be recorded at the time of service or no later than the end of the shift. One resident, a female admitted on 1/15/2026, had a documented bathing preference of Monday, Wednesday, and Friday evenings, but her 30‑day ADL-bathing task record lacked any bath or refusal entry for a scheduled Monday. During interview, she stated she was able to take showers on her scheduled days, did so independently, and had not missed any showers. Another female resident admitted on 12/31/2026, with the same Monday, Wednesday, and Friday evening bathing preference, had no bath or refusal entries for two scheduled days. She reported she was able to take showers on her scheduled days with assistance from one staff member. A third resident, a [AGE]‑year‑old female admitted on 1/21/2026 with a Monday, Wednesday, and Friday daytime bathing preference, had no bath or refusal entry for a scheduled Monday. During interview, he initially stated he had not received a shower, but his family member corrected him, stating he had received one, and he then agreed, adding he was unsure if he had missed a shower. A fourth [AGE]‑year‑old female resident admitted on 12/10/2026, with a Tuesday, Thursday, and Saturday evening bathing preference, had multiple dates with no bath or refusal entries in the EMR. She stated she was able to take showers on her scheduled days with staff assistance and commented that she paid for three times a week and did not take bed baths, though she could. CNAs and RNs interviewed confirmed they were responsible for documenting showers and refusals in the EMR/POC, and the DON and Administrator acknowledged that missing documentation occurred, citing reasons such as login issues, crisis situations, and staff moving from task to task and losing track, despite the written policy requiring complete, accurate, and timely documentation.
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