Incomplete ADL Documentation Due to Lack of CNA Access to Electronic Devices
Penalty
Summary
The facility failed to ensure that medical record documentation of activities of daily living (ADLs) was accurate and complete for one of five sampled residents. The resident in question had multiple diagnoses, including diabetes mellitus, abnormal posture, muscle weakness, generalized osteoarthritis, heart failure, hypertension, and dementia, and was assessed as having severe cognitive impairment. According to the Minimum Data Set (MDS), the resident required significant assistance with most ADLs and had a history of rejecting care on several occasions during the assessment period. A review of the resident's ADL records over a ten-day period revealed multiple instances of missing documentation for essential care tasks such as eating, bed mobility, personal hygiene, toilet hygiene, and oral hygiene across various shifts. During an interview and record review, the Director of Nursing (DON) confirmed the missing documentation and attributed the issue to the theft of iPads used by CNAs for documentation, which had not been replaced. As a result, CNAs had to share computers with nurses, leading to delays and omissions in documentation due to limited access.