Failure to Ensure Complete and Accurate Nurse Aide Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation by Nurse Aides for a resident with multiple diagnoses, including dementia, altered mental status, anxiety disorder, and malnutrition. The resident was assessed as having moderately impaired cognition and required staff assistance for activities of daily living (ADLs), including eating, personal care, bed mobility, and transfers. Observations confirmed that the resident appeared clean, well-dressed, and had access to water and reading material. However, a review of Nurse Aide documentation for April and May revealed significant inconsistencies in recording care tasks such as behavior symptoms, transferring, bed mobility, bowel movements, toileting hygiene, intake and output, toilet use, oral hygiene, personal hygiene, showering/bathing, snacks, eating, and amount eaten. Documentation was incomplete for the majority of days reviewed in both months. During an interview, the Director of Nursing Services (DNS) was unaware of the inconsistent documentation and acknowledged that Nurse Aides should be documenting all tasks every shift. The facility was unable to provide a policy for Nurse Aide documentation when requested. The deficiency centers on the lack of consistent and complete documentation of care provided to a dependent resident, as required by accepted professional standards.