Incomplete Documentation of Incontinent Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the medical record for a resident with hemiparesis and vascular dementia was complete and accurate regarding incontinent care provided. The resident, who had moderately impaired cognition and required maximal assistance with ADLs, was frequently incontinent of bowel and bladder. The care plan directed staff to provide incontinent care, and facility documentation indicated that the resident alleged not receiving ADL care from the morning and having the call light on for 45 minutes without response. An incident summary confirmed that the nurse aide assigned to the resident did not provide any morning care/ADL care and only checked on the resident at the start of the shift and gave incontinent care before lunch, but this was not documented in the clinical record. Review of the nurse aide documentation showed the last recorded incontinent care was at 6:59 AM, with no further documentation of care between 7 AM and 3 PM. The nurse aide later stated she provided care around midday but did not document it, citing lack of time before her shift ended. Interviews with facility leadership confirmed they could not provide documentation of the care, and facility policy required documentation to be completed at the time of service or by the end of the shift. This failure resulted in an incomplete and inaccurate medical record for the resident.