Failure to Document ADL Care and Services in Resident Medical Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation of Activities of Daily Living (ADLs) for three sampled residents. For one resident with diagnoses including Parkinson’s, dementia, anemia, and hypotension, review of the medical record revealed missing documentation for multiple ADL tasks such as bed mobility, toileting, bathing, dressing, and incontinence care on several dates. The care plan indicated the resident required assistance with all ADLs, but the records did not reflect that care was provided or documented as required. The Director of Nursing (DON) confirmed that documentation was missing for the specified dates and acknowledged that she expected to see records of tasks performed. Another resident, with a history of diabetes, Alzheimer’s disease, hypertension, and dementia, was also found to have incomplete documentation regarding incontinence care and toileting. The care plan specified that the resident was dependent on staff for these tasks, yet the ADL records showed only one or two instances of incontinence care documented on several days, and no documentation at all on one date. The DON verified the absence of documentation for incontinence care and stated that staff were expected to document these services. A third resident, with multiple chronic conditions including diabetes with foot ulcer, hyperthyroidism, and peripheral vascular disease, had missing ADL documentation for bed mobility, toileting, transfers, and other care activities during both day and evening shifts on several dates. The care plan indicated the resident required extensive assistance for these activities. The DON confirmed that documentation was not completed for the identified dates. Facility policies reviewed required that all care and services provided be documented in the resident’s medical record, including details such as date, time, and the name and title of the individual providing care.