The breakdown in communication centered on Resident #1, whose scheduled bath days were Monday, Wednesday, and Friday. Multiple staff members acknowledged the resident frequently refused showers but would tolerate bed baths. However, even during bed baths, the resident's hair wasn't washed or combed.
CNA C told inspectors during a November 25 interview that when Resident #1 received a bed bath, "she did not have her hair washed or combed." She admitted it was "possible she missed documenting the refusals" in the resident's chart, despite facility policy requiring staff to document all refusals and notify the charge nurse.
CNA S, interviewed 10 minutes later, said Resident #1 "often refused hair care." She couldn't recall whether she documented these refusals or informed nurses. "Sometimes, she did not complete the required documenting," she told inspectors.
The communication gaps extended up the chain of command.
RN W acknowledged she knew Resident #1 "often refused ADL care" but said she "did not document Resident #1's ADL refusals in the progress notes." This violated the facility's own policy requiring nurses to document refusals and make necessary notifications to family and physicians.
LVN N, when interviewed the following morning, said she "was not aware Resident #1 was not receiving baths, showers, or hair care." Inspectors attempted to contact LVN T by phone regarding the resident's care refusals, but received no response despite leaving contact information.
The facility's Director of Nursing expressed clear expectations during her November 26 interview. She said residents should receive their scheduled showers and baths, and if staff couldn't complete them, "they were supposed to notify the charge nurse or herself." Staff were also required to document when baths, showers, or hair care wasn't completed or refused.
But those expectations weren't being met.
The Assistant Director of Nursing explained the potential consequences of the documentation failures. If nurses weren't made aware of care refusals, "there could be skin break down and it could also affect the resident's mental health."
The Administrator echoed the policy requirements during her interview, saying staff were supposed to document refusals and notify charge nurses, who would then document in progress notes and make required notifications to family and physicians "if necessary."
Facility policy, dating to 2001 and revised in 2017, explicitly required documentation of all services provided to residents, including "whether the resident refused the procedure/treatment" and "notification of family, physician or other staff, if indicated."
The policy outlined seven specific requirements for documenting procedures and treatments, including the date and time care was provided, the name and title of caregivers, assessment data, how residents tolerated treatments, any refusals, and appropriate notifications.
These documentation requirements weren't merely administrative. The policy stated that medical records "should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care."
Without proper documentation of Resident #1's refusals, the interdisciplinary team couldn't develop strategies to encourage hygiene compliance or monitor for complications. The nursing staff remained unaware of ongoing care gaps that could lead to skin problems or psychological distress.
The inspection revealed a facility where front-line staff understood basic care refusal protocols but admitted they sometimes didn't follow them. CNAs knew they should document refusals and notify charge nurses. Charge nurses knew they should document in progress notes and contact families when appropriate.
Yet Resident #1 continued to miss scheduled hygiene care without proper documentation or supervisory awareness. The breakdown occurred at multiple levels: CNAs who "sometimes" didn't document, an RN who knew about refusals but didn't record them, and an LVN who remained unaware of ongoing care issues.
The facility's 2017 policy revision hadn't prevented the documentation gaps that left Resident #1's care team operating without crucial information about the patient's hygiene needs and preferences.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Trinity Rehabilitation & Healthcare Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Trinity Rehabilitation & Healthcare Center
- Browse all TX nursing home inspections