Failure to Document ADL Intake and Output for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure that activities of daily living (ADL) documentation was completed for one of three sampled residents reviewed for ADLs. Specifically, for a resident with diagnoses including hemiplegia, hemiparesis, muscle weakness, cerebral infarction, and bipolar disorder, there was no documentation of intake and output or meal percentages for a seven-day period leading up to a hospital stay. The resident was assessed as cognitively intact with a BIMS score of 15. Review of facility policy indicated that staff were required to document percentage consumed in the electronic health record (EHR), but no such documentation was found for the specified period. The regional nurse consultant confirmed that all available ADL documentation had been provided and acknowledged the absence of a generalized ADL policy, as well as the lack of a specific policy for documenting eating or intake and output.