Incomplete Documentation of Resident Care by Nurse Aides
Penalty
Summary
The facility failed to ensure complete and consistent documentation in the clinical record for a resident with multiple complex medical conditions, including type 2 diabetes mellitus with hyperglycemia, congestive heart failure, obesity, and muscle weakness. The resident required significant assistance with activities of daily living (ADLs) such as eating, toileting hygiene, showering, personal hygiene, bed mobility, and transfers, as identified in the admission MDS and care plan. Despite these needs, a review of the March 2025 documentation survey report revealed multiple instances where nurse aide documentation was missing for key care areas, including bladder and bowel elimination, eating, personal hygiene, showering, toileting hygiene, amount eaten, bowel and bladder diary, fluid intake, and output across several dates and shifts. The facility's policy required CNAs to complete flow sheets in the electronic health record for each resident every shift, documenting all care provided. However, interviews with the DNS confirmed that nurse aide compliance with documentation was inconsistent and ongoing education was being provided to address missing entries. The lack of complete documentation was observed despite the resident's complex care needs and the facility's established procedures for record-keeping. The resident in question was ultimately transferred to the emergency department following a change in condition and did not return to the facility.