Incomplete ADL-Bathing Documentation for Two Residents
Penalty
Summary
Surveyors identified that the facility failed to maintain complete and accurate ADL-bathing documentation in the electronic medical record for two residents. For an 82-year-old female resident with dementia, type 2 diabetes, and a need for assistance with personal care, review of her quarterly MDS showed she had a BIMS score of 15/15 and was dependent on staff for showering/bathing. Her 30‑day task record reflected a preference for bathing on Tuesdays, Thursdays, and Saturdays, but there were no bath or refusal entries documented for multiple specified dates over February and March, despite her admission date of 1/1/2026. During observation, she appeared clean and groomed and reported that she was able to take showers on scheduled days but sometimes refused when offered early in the morning, preferring showers after dinner. A male resident with spinal stenosis, type 2 diabetes, and a need for assistance with personal care also had incomplete ADL-bathing documentation. His quarterly MDS showed a BIMS score of 15/15 and a need for substantial to maximum assistance with showering/bathing, with a documented preference for bathing on Tuesdays, Thursdays, and Saturdays. However, his 30‑day task record lacked bath or refusal entries for the same series of dates, despite a readmission date of 8/9/2025. During observation, he was in his room with clean clothes and a groomed appearance and stated he required help with showers. CNA A reported that showers were required to be documented in the plan of care but admitted that when work was very busy, she did not chart, even though she stated she always offered showers. CNA B stated that shower documentation was in the system and must be completed, and suggested the male resident probably refused scheduled showers. The DON stated that showers and refusals were required to be documented and described a process in which CNAs notify the nurse of refusals and attempts are made and documented, but the records for these residents did not reflect such documentation.
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