Failure to Document ADL Assistance for Multiple Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation of activities of daily living (ADL) for three residents who required varying levels of assistance with transfers and personal hygiene. According to the facility's own Charting and Documentation policy, all services provided, progress toward care plan goals, and any changes in a resident's condition must be documented in the medical record. However, record reviews revealed multiple instances where there was no documented evidence that required assistance with personal hygiene and transfers was provided during specific shifts for all three residents. These residents had documented ADL self-care performance deficits and required supervision, partial to moderate, or total assistance for transfers and personal hygiene as outlined in their care plans and Minimum Data Set (MDS) assessments. Interviews with the MDS Coordinator and the Director of Nursing confirmed that Certified Nursing Assistants (CNAs) were responsible for documenting the assistance provided, and acknowledged that documentation was missing for the identified dates and shifts. The lack of documentation affected all three residents, each of whom had care plans specifying their need for assistance with ADLs, and the missing records spanned multiple days and shifts over several months.