Incomplete Documentation of Incontinence Care Due to EMR Limitations
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for two residents who required total care for toileting hygiene due to severe cognitive impairment and incontinence. Record reviews showed that both residents' care plans required routine rounding and incontinence care, but the CNA flow sheets for November 2025 did not accurately document each instance of incontinence care or checks. Documentation was incomplete, with no indication that incontinence care was provided as required, despite staff statements that care was given every two hours. Interviews with staff revealed that recent updates to the electronic medical record system had removed the option for CNAs to chart each episode of incontinence care or checks, limiting documentation to one or two times per shift. The DON confirmed that she was unaware of how long this documentation issue had persisted and acknowledged responsibility for ensuring complete and accurate medical records. The facility's policy allowed for electronic medical records in lieu of paper records, but the system's limitations led to incomplete documentation of care provided.