Incomplete Clinical Documentation for ADL Care
Penalty
Fine: $23,56582 days payment denial
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that clinical records for a resident were complete and contained accurate information, as required by accepted professional standards. Record review revealed multiple instances of missing documentation for activities of daily living (ADL) care, including bathing/showering, elimination (urinary and bowel), oral hygiene, toileting hygiene, scheduled toileting programs, and eating. These omissions occurred across both day and night shifts on various dates. The lack of documentation was identified during a review of the resident's medical record and was confirmed through interview with facility staff.