Failure to Maintain Complete and Accurate Bathing Documentation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete, accurate, readily accessible, and systematically organized medical record for one resident, specifically regarding documentation of showers and bed baths. The resident was an adult male with diagnoses including Parkinsonism, chronic ischemic heart disease, chronic respiratory failure, anxiety disorder, PTSD, and heart disease. His admission MDS showed intact cognition (BIMS 13) and a need for substantial/maximal assistance with personal hygiene, and his care plan required staff assistance with bathing/showering. However, review of his ADL records for February and March showed "No" for showers/bed baths, with no documentation of refusals, and the facility’s shower binder contained only one shower sheet indicating a refusal on a single date. During observations, the resident appeared clean and well-groomed, but a family member reported that on a recent visit the resident had food on his mouth and face, crust on his eyes, and long fingernails with buildup underneath, and expressed concern that he had not received a shower in a long time. The resident himself stated he received showers but could not recall how often or when. Multiple staff interviews revealed inconsistent information about the resident’s scheduled shower days and shifts, with some staff stating his showers were scheduled for Mondays, Wednesdays, and Fridays on the evening shift, while others stated different days or could not recall precisely when showers were last provided. Record review and staff interviews further showed that the resident’s electronic health record had showers scheduled on the wrong shift (morning instead of evening), and there was no documentation in the electronic record or shower sheets confirming that showers or bed baths had been provided. CNAs and LVNs stated that CNAs were responsible for documenting showers/bed baths in the electronic record and on shower sheets, and nurses were to sign the shower sheets, but several staff, including the ADON and Administrator, were unaware that shower sheets were not being completed for this resident. One CNA reported providing bed baths but admitted not documenting them and not knowing where the shower sheets were located. Facility leadership and nursing staff acknowledged that without documentation they could not verify whether the resident had actually received showers or bed baths, and some staff stated that lack of showers could lead to infections or dry skin.
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