Failure to Accurately Document Toileting Hygiene After Incontinent Episodes
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, as evidenced by discrepancies in documentation related to toileting hygiene following incontinent episodes. Specifically, the resident experienced bladder and bowel incontinence on several occasions during the night shift, but the Geriatric Nursing Assistant (GNA) documented 'Not Applicable' (NA) for the Toileting Hygiene task instead of indicating whether care was provided or refused. The Director of Nursing (DON) confirmed that the expectation is for GNAs to document if care was provided or if the resident refused care, using the 'Resident Refused' (RR) option when applicable. During interviews, the GNA responsible for the documentation stated that 'NA' was used when a task did not apply, but in this case, the GNA intended to document a refusal but was unable to do so and therefore selected 'NA.' This resulted in incomplete and inaccurate records regarding the resident's care after incontinent episodes, as the documentation did not accurately reflect whether hygiene care was provided or refused by the resident.