Incomplete CNA Documentation of ADL Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required physical assistance with activities of daily living (ADLs). Review of the resident's CNA ADL Flow Sheets over a three-month period revealed multiple instances where documentation was left incomplete or blank across all three shifts. Specifically, there were numerous days in each month where ADL care areas were not documented by CNAs, despite facility policy requiring that all care provided be recorded in the electronic health record by the end of each shift. Interviews with CNAs and the Director of Nursing confirmed that it is the facility's expectation for CNAs to document all ADL care in the electronic medical record by the end of their shift, and that documentation should not be left incomplete. The resident involved had significant medical needs, including acute and chronic respiratory failure, myotonic muscular dystrophy, and required staff assistance for multiple ADLs as indicated in their care plan and MDS assessment. Despite these needs and clear policy, documentation lapses occurred repeatedly.