Failure to Consistently Document ADL Care Provided to Residents
Penalty
Summary
The facility failed to consistently document the provision of Activities of Daily Living (ADL) care for two residents who required assistance. For one resident with diagnoses including morbid obesity, osteoarthritis, muscle weakness, and difficulty walking, multiple blank entries were found in the ADL documentation forms over several months. These blank entries indicated that tasks such as personal hygiene, turning and positioning every two hours, bladder and bowel continence care, rolling left and right, and use of a preventative mattress were not documented as completed on numerous shifts across June, July, and August. The resident was assessed as cognitively intact, and the documentation gaps were identified through a review of the resident's medical records and documentation survey reports. A second resident, admitted with heart failure, muscle weakness, and morbid obesity, also had multiple blank spaces in their ADL documentation forms. These omissions included personal hygiene, turning and repositioning, bladder and bowel continence care, rolling left and right, and use of a preventative mattress, with missing documentation noted on various day, evening, and night shifts. The review of documentation for this resident covered the months of June and July, with similar patterns of incomplete records for required care tasks. Interviews with staff revealed that CNAs were responsible for turning and positioning residents who were incontinent and in bed, and that nurses provided reports to CNAs identifying which residents required this care. The Director of Nursing (DON) confirmed that if care was not documented, it was considered not done, and stated that both nurses and CNAs were responsible for completing ADL documentation. The DON also indicated that the Assistant Director of Nursing (ADON) and nurse manager were tasked with auditing ADL documentation for completion. Facility policy required that documentation in the medical record be objective, complete, and accurate.