F0842

D

Incomplete Documentation of Required Bathing and Grooming Care

New Haven, Connecticut Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate clinical records reflecting the provision of required hygiene care, including weekly showers or bed baths, for two residents. For one resident with severe protein calorie malnutrition, adult failure to thrive, type II diabetes mellitus, and a stage 3 pressure ulcer, the MDS showed moderately impaired cognition and dependence on staff for most ADLs, with the care plan calling for total care for showering and grooming. Point of Care (POC) documentation for December and January showed only one shower and a few partial bed baths, with multiple week-long gaps where no shower or bed bath was recorded, and the clinical record contained no documentation of refusals during those periods.

For another resident with vascular dementia without behavioral disturbances and adult failure to thrive, the MDS showed severely impaired cognition and a need for assistance with ADLs, and the care plan specified assistance with showering on a set weekly schedule. POC records for December, January, and March showed only sporadic showers or bed baths, with several weeks lacking any documented shower or bed bath, and no refusals recorded in the clinical record. A grievance documented that this resident was found with feces under the nails requiring soaking to remove. The DON stated that residents should receive at least a weekly shower or complete bed bath and that care should be documented before the end of the shift, and acknowledged that the record did not show a shower or bed bath for the week preceding the grievance. The facility’s Bathing and Grooming Care policy required at least weekly showers and associated grooming, but requested policies for nurse aide documentation or Kardex/Care Card were not available.