Incomplete Documentation of ADL Bathing Care in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident in accordance with accepted professional standards and its own policy. A female resident with sequelae of cerebral infarction, vascular dementia without behavioral disturbance, and a need for assistance with personal care had a quarterly MDS showing a BIMS score of 00, indicating her cognition could not be scored and she could not be understood, and that she required maximal assistance with bathing and was totally dependent on staff for personal hygiene and toileting. Her ADL self-care performance deficit care plan listed shower/baths as not applicable. Review of her ADL completed bath activity for the last 30 days showed she was on a Monday, Wednesday, and Friday bathing schedule, but there were no showers, baths, or sponge baths documented in the medical record for the period reviewed. Further record review of the resident’s shower sheets for the same time frame showed multiple showers and a bed bath were actually provided on specific dates, demonstrating that care was given but not reflected in the Nursing Assistant ADL Flow Sheet or the medical record. During interviews, the DON stated she did not know if shower sheets were part of the resident’s medical record and indicated that Medical Records was responsible for documentation uploads, emphasizing the importance of a complete and accurate medical record to account for all care provided. Medical Records staff stated that shower sheets were not uploaded into the medical record and were considered for facility information only, although they were collected and stored for five years. The facility’s policy on the content of the medical record, however, listed Nursing Assistants ADL Flow Sheets as part of the required contents, underscoring that the resident’s ADL bathing care was not accurately documented in the official clinical record.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.