Incomplete Documentation of Scheduled Showers in Clinical Records
Penalty
Summary
Surveyors identified a deficiency in the facility’s documentation of showers and hygiene care, as required by its own policies and state regulations. The facility’s Bath, Shower/Tub policy required documentation of the date and time a shower or tub bath was performed and the name and title of the staff who assisted, and the ADL policy required appropriate support and assistance with hygiene, including bathing. Review of the electronic shower task documentation for four residents showed multiple dates on which showers were scheduled but lacked any documentation that the showers were provided or completed. For one resident with diabetes and hypothyroidism, the shower task records for February and March 2026 lacked documentation of showers on six specified dates. For a second resident with diabetes and hypertension, the shower task records for February and March 2026 lacked documentation of showers on six specified dates. For a third resident with hypertension and GERD, the shower task records for February and March 2026 lacked documentation of showers on nine specified dates. For a fourth resident with Parkinson’s disease, overactive bladder, and diabetes, the February 2026 shower task records lacked documentation of showers on seven specified dates. During an interview, the DON confirmed that the clinical records for all four residents did not contain complete documentation regarding showers and acknowledged that showers should be completed as scheduled in the task system and documented when done.
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