Inaccurate Documentation of ADL Care Due to Assignment Restrictions in EMR
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident by not ensuring that the staff member who delivered care was the same individual who documented the care in the electronic medical record (EMR). According to the facility's policy, all pertinent observations and services performed should be recorded in the patient's medical record by the person providing the care. In this case, a resident with Alzheimer's disease and moderate cognitive impairment required substantial assistance with bathing and had a care plan specifying that only female CNAs should provide shower assistance. On a specific date, the EMR indicated that a male CNA documented providing the resident's shower, despite the resident's preference and care plan intervention. Interviews with staff revealed that the female CNA actually provided the shower, but was unable to document this in the EMR because she was not assigned to the resident. Instead, the male CNA, who was not assigned to the resident and did not provide the care, documented the shower as completed. The Assistant Director of Nursing confirmed that only assigned staff could document care in the EMR, and if another staff member provided care, the assigned person would have to be notified to record it. This process resulted in inaccurate documentation of care provided to the resident.