Incomplete and Inaccurate CNA Documentation for Resident Positioning
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident with significant medical needs, including cerebral infarct, end-stage kidney disease, and pressure ulcers. According to the facility's policy, staff are required to document all assessments, observations, and services provided in the resident's medical record accurately and completely. However, a review of the resident's Activities of Daily Living (ADL) flow sheets revealed multiple instances where documentation related to bed positioning was either left blank or marked as 'not applicable' (NA) during several shifts. These omissions occurred despite the resident being dependent on staff for bed positioning, as indicated in the Minimum Data Set (MDS) admission assessment. During an interview, the Director of Nursing (DON) confirmed that the assigned CNA was responsible for completing the flow sheet and acknowledged that the documentation should not have been left blank or marked as NA for the specified dates and times. The DON further stated that the CNA flow sheet for this resident was not complete or accurate, confirming the deficiency in maintaining proper medical records as required by facility policy and professional standards.