Failure to Consistently Document ADL Care Provided
Penalty
Summary
The facility failed to consistently document Activities of Daily Living (ADL) care provided to a resident who required assistance. Specifically, a review of the ADL documentation for one resident with diagnoses including depression, muscle weakness, and difficulty walking, revealed multiple instances where documentation was left blank. These omissions included bed mobility, dressing, personal hygiene, toilet use, walking in the corridor and room, bowel and bladder elimination, eating, and nutrition intake on specified shifts. The resident was assessed as having intact cognition, with a BIMS score of 15 out of 15. Interviews with facility leadership confirmed that CNAs were responsible for documenting ADL care, and that the DON and ADON were tasked with auditing this documentation for completion. The facility's policy required that ADLs be documented in real time or immediately after care tasks were completed for each shift. Despite these requirements, the documentation was incomplete for the resident on several occasions, as identified during the review.