Incomplete ADL Documentation for Dependent Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who required total assistance with activities of daily living (ADLs) due to multiple diagnoses, including peripheral artery disease with bilateral foot gangrene, diabetic neuropathy, acute lymphoblastic leukemia in remission, chronic pain, and chronic urinary retention with an indwelling catheter. According to the resident's care plan and Minimum Data Set (MDS) assessment, the resident was totally dependent on staff for all ADLs, including transfers with a mechanical lift, repositioning, and toileting/incontinent care. A review of the resident's ADL Flow Sheets, which were to be completed daily by CNAs, revealed that documentation was frequently left blank across all shifts over a 15-day period. Specifically, the flow sheets were incomplete for 10 out of 15 days on the day shift, 11 out of 15 days on the evening shift, and 13 out of 15 days on the night shift. Interviews with staff, including a CNA, the Unit Manager, and the DON, confirmed that ADL documentation was required to be completed by the end of each shift and in a timely and accurate manner, as outlined in facility policy.