Incomplete CNA Documentation of Resident ADL Tasks
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident when multiple shifts lacked Certified Nursing Assistant (CNA) documentation for various Activities of Daily Living (ADL) tasks throughout July 2024. A review of the resident's clinical documentation revealed missing entries across a wide range of care areas, including behavior, bladder and bowel continence, bowel movements, fall interventions, fluid intake, and numerous GG assessment items such as transfers, hygiene, and ambulation. These omissions were present on multiple dates and shifts, indicating a pattern of incomplete documentation. Interviews with facility staff confirmed the documentation lapses. A CNA acknowledged that there were times when ADL tasks were completed but not documented, despite being aware of the expectation to finish charting by the end of each shift. The CNA also recognized that incomplete documentation could result in miscommunication about the resident's care, such as the risk of unnecessary medication administration. A licensed nurse stated that CNAs were responsible for documenting every shift and that charge nurses were expected to ensure this was done, but admitted that this oversight was not always performed. Further confirmation came from the Director of Staff Development and the Director of Nurses, both of whom verified the presence of multiple missing documentation entries for the resident. They stated that the lack of complete CNA documentation could lead to miscommunication between shifts, difficulty in proving that care tasks were completed, and challenges for other departments in accurately assessing the resident. The facility's policy and procedure on charting and documentation required that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented objectively, completely, and accurately in the medical record.