Incomplete ADL Documentation for Scheduled Showers
Penalty
Summary
The facility failed to ensure complete and accurate clinical record documentation for one resident, identified as CR 1. This resident was admitted with diagnoses including atrial fibrillation, and the care plan specified that staff were to provide showers twice weekly. Review of the facility’s ADL (Activities of Daily Living) Verification Worksheet showed that between January 21, 2026, and February 5, 2026, there was no documentation to support that showers were offered or provided twice weekly on four occasions as care planned. In an interview on March 12, 2026, at 1:14 p.m., the Director of Nursing was unable to provide documentation that the showers had been provided as identified in the resident’s plan of care, indicating incomplete and inaccurate clinical record documentation. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
