Failure to Document ADL Care for Dependent Residents
Penalty
Summary
The facility failed to consistently document care provided to dependent residents in accordance with its own policies and accepted professional standards. For three residents with moderate to severe cognitive impairment and significant assistance needs for activities of daily living (ADLs), there were multiple instances where documentation of personal hygiene and toilet use was missing across all shifts for extended periods. The lack of documentation was identified through review of the Documentation Survey Reports (DSRs) and confirmed by interviews with staff, who acknowledged that all care provided should be recorded in the electronic medical record without any blanks. Specifically, for one resident with dementia and diabetes, there were numerous days in May where personal hygiene documentation was absent across all three shifts. Another resident with seizures and muscle weakness also had multiple days in May with missing documentation for personal hygiene. A third resident with Alzheimer's disease and severe cognitive impairment had extensive gaps in documentation for both personal hygiene and toilet use throughout January, with missing entries on nearly every day and shift reviewed. Interviews with CNAs, an LPN, and the DON confirmed that CNAs are responsible for documenting ADL care in the electronic record, and that there should not be any blanks in the documentation. Facility policies reviewed by surveyors also required that all skilled and unskilled services, including ADL care, be documented for each resident. The failure to document care as required was observed and verified by both staff and surveyors during the investigation.