Failure to Document ADL Care in Resident Medical Record
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
Facility nursing staff failed to accurately document activities of daily living (ADL) care in the medical record for a resident on three separate shifts. Specifically, there was no documentation of ADL care provided on the day shift of 1/15/25, the evening shift of 1/20/25, and the night shift of 1/23/25. This deficiency was identified during a complaint survey following a family report that the resident did not receive necessary ADL care, which allegedly contributed to the development of a preventable wound. The Director of Nursing (DON) confirmed during an interview that the nursing staff did not document the required ADL care for the resident on the specified dates.