Inaccurate Documentation of Showers and Oxygen Use for Multiple Residents
Penalty
Summary
Facility staff failed to maintain accurate clinical documentation for multiple residents, resulting in records that did not truthfully reflect the care provided or the residents’ clinical status. For one resident with cirrhosis of the liver, muscle weakness, sickle-cell disease, and heart failure, the physician’s order directed showers twice weekly on specific days and times. The Treatment Administration Record and CNA documentation for a specified date in January showed that a shower with skin check was completed and that refusals were documented. However, during an interview that same day, the resident stated they did not take a shower, did not want one, and had communicated this to staff. A second resident, with hemiplegia/hemiparesis, COPD, and muscle disease, also had a physician’s order for showers twice weekly on designated days and shifts. The TAR and CNA documentation for the same January date indicated that a shower with skin check was completed and refusals were documented. In contrast, during an interview, this resident stated they did not take a shower and expressed that they would not shower at the facility. The RN assigned to both residents confirmed in an interview that the residents did not receive showers and were instead washed in bed, and acknowledged that she had documented showers as completed rather than documenting refusals and bed baths. For a third resident with COPD, chronic respiratory failure with hypoxia, and hypertension, the medical record included a care plan and physician’s order for continuous oxygen via nasal cannula at 2–3 L/min. A quarterly MDS assessment documented that the resident used oxygen therapy while in the facility. However, the quarterly Safe Smoker Assessment completed in January recorded that the resident did not have an order for continuous or PRN oxygen and identified the resident as a safe smoker who preferred cigarettes, with supervision recommended as protective equipment. In a subsequent interview, the resident stated they did not smoke and had not smoked in almost ten years. The unit manager later reviewed the Safe Smoker Assessment and physician’s orders and characterized the inaccurate documentation as an oversight.
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