Incomplete CNA Documentation for ADL Care
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) flow sheets were complete and accurate for two residents. For the first resident, who had severe cognitive impairment and was non-ambulatory due to a history of stroke with right hemiparesis and aphasia, multiple sections of the CNA flow sheets for November were left blank. These omissions included documentation of personal hygiene, perineal hygiene, and bathing across various shifts. Interviews with the CNA, Nurse Manager, and Assistant Director of Nursing (ADON) confirmed that CNAs were responsible for documenting all care in the Point of Care (POC) system and that there should not be any blanks in the documentation, as per facility policy. For the second resident, who was dependent in all activities of daily living due to quadriplegia and other medical conditions, similar deficiencies were found. The admission record for this resident was missing medical diagnoses, and the CNA flow sheets for November contained multiple blank sections for personal hygiene and bathing tasks across all shifts. The Medication Administration Record and care plan did list the resident's diagnoses, but the lack of documentation in the CNA flow sheets indicated that care provided was not properly recorded. Facility policy required that all ADL and functional abilities assistance be recorded in the POC within the electronic medical record. Despite this, the review of records and staff interviews revealed that documentation was incomplete for both residents, with multiple care tasks left unrecorded. This failure to maintain accurate and complete medical records was identified during the survey and confirmed by staff interviews and review of facility policy.