Incomplete Incontinence Documentation for Dependent Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with significant ADL self-care deficits, specifically regarding incontinence documentation. The resident, who had diagnoses including Alzheimer's, diabetes, weakness, depression, and dysphagia, was assessed as severely impaired in daily decision-making and required total assistance with toileting and other ADLs. The care plan required incontinence care as needed and documentation of any significant decline in function. However, review of the incontinence logs for October and November showed that documentation was only completed once per day on several dates, rather than every two hours as expected. Multiple staff interviews confirmed that the standard practice was to check and change residents every two hours or as needed, but this was not reflected in the documentation for the resident in question. The Director of Nursing Services acknowledged the documentation concern but did not provide additional information. The deficiency was identified through observation, record review, and staff interviews, indicating a failure to maintain clinical records in accordance with accepted professional standards.