Failure to Consistently Document ADL Care in Resident Records
Penalty
Summary
Facility staff failed to consistently document Activities of Daily Living (ADL) care in the Documentation Survey Report (DSR) for multiple residents, as required by facility policy. For three out of four residents reviewed, there were missing entries in the DSR and progress notes regarding whether ADL care was provided or refused on specific dates and shifts. The residents involved had significant medical conditions, including quadriplegia, acute respiratory failure, dysphagia, bipolar disorder, dementia, hyperlipidemia, diabetes, hypertension, and chronic pain syndrome. Their cognitive statuses ranged from intact to severely impaired, as indicated by their Brief Interview of Mental Status (BIMS) scores. Interviews with staff revealed that Certified Nursing Assistants (CNAs) were responsible for documenting ADLs using a mobile app, and documentation was expected to be completed by the end of each shift. The Director of Nursing (DON) and Unit Manager (UM) confirmed that blank documentation fields did not necessarily mean care was not provided, but acknowledged that documentation should not be left incomplete. The facility's ADL Documentation Policy required all nursing staff and caregivers to document ADLs as part of their daily routines, with supervisors responsible for regular compliance checks. Despite these requirements, the review found multiple instances where ADL documentation was missing, indicating a failure to follow established policy and professional standards.