Incomplete ADL Documentation for Dependent Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents who were dependent on staff for all activities of daily living (ADLs). For one resident with diagnoses including cerebral infarction, diabetes mellitus, and osteomyelitis, review of ADL flow sheets over multiple weeks revealed numerous shifts where all ADL care areas were left blank, indicating incomplete documentation. Specifically, there were missing entries across all three shifts on several days, despite the resident's total dependence on staff for care. Similarly, another resident with multiple diagnoses such as anemia, osteoarthritis, diabetes mellitus, bipolar disorder, hypertension, and atrial fibrillation also had incomplete ADL documentation. Over a period of nearly a month, there were multiple days where entire shifts lacked any documentation of ADL care. The facility's policy requires that each resident have an active medical record with accurately documented information, and the unit manager confirmed that CNAs are responsible for completing this documentation by the end of their shift.