Failure to Document Personal, Bowel, and Bladder Care for a Resident
Penalty
Summary
The facility failed to document personal, bowel, and bladder care for one resident, as evidenced by missing documentation in the electronic medical record for multiple shifts. The resident in question had a history of urinary tract infection, dementia, type two diabetes mellitus, congestive heart failure, and atrial fibrillation, and was assessed as requiring substantial to maximum assistance for most activities of daily living. The care plan specified that the resident should be kept neat and clean, with incontinence checks and perineal care as needed. Despite these requirements, documentation was absent for three day shifts and thirteen night shifts, even though the resident was known to be incontinent and bed bound. Interviews with staff revealed that empty blanks in the documentation system indicated that care was not documented, and it was acknowledged that some CNAs were reluctant to chart care provided. The unit manager confirmed that the expectation was for CNAs to document all care given, and that empty blanks meant documentation was not completed, though she could not confirm whether care was actually provided. The resident's representative reported that the resident had no skin breakdown prior to admission but developed redness to the sacral region by discharge, further highlighting the lack of documented care.