Incomplete Documentation of ADLs in Resident Medical Record
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for one resident, as evidenced by missing documentation in the Activities of Daily Living (ADL) records. The resident, who had multiple diagnoses including atrial fibrillation, hypertension, diabetes mellitus, and a history of nontraumatic intracerebral hemorrhage, was assessed to have intact cognitive function. The resident's care plan required monitoring and documentation of ADLs, with interventions to encourage self-care where possible. Upon review, the ADL records for the resident showed blank entries for all ADLs during specific shifts on several dates. Interviews with the RN and DON confirmed that Certified Nurse Aides (CNAs) are responsible for completing these records and that blank entries indicate tasks were not documented, even though care may have been provided. The facility's policy requires CNAs to document all care provided, including any refusals or unusual occurrences, in the resident's medical chart during their assigned shift.