Incomplete Documentation of Activities of Daily Living for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required staff assistance with all activities of daily living (ADLs), including toileting, showering, and bathing. The resident was cognitively intact and had a care plan indicating dependence on staff for hygiene and grooming, with specific instructions for staff to assist as needed and to document both care provided and refusals. However, review of the resident's documentation for October and November revealed multiple dates with missing entries for morning and evening care, as well as inconsistencies in recording refusals of baths or showers. Interviews with certified nursing assistants (CNAs) and supervisory staff revealed that the resident frequently refused care from certain staff members but would accept care from others. When care was provided by a CNA not assigned to the resident, that CNA was unable to document the care in the electronic medical record due to system limitations. Additionally, the electronic system only allowed documentation on assigned bath days and for the day shift, preventing accurate recording of care provided at other times or by other staff. As a result, care that was provided or refused was often not documented, leaving gaps in the resident's medical record. Supervisory staff, including the Director of Nursing and Assistant Director of Nursing, confirmed the missing documentation and acknowledged that the only record of ADL care was the electronic medical record, with no alternative documentation available. The administrator and previous Director of Nursing also confirmed the deficiency and noted that a change in computer software had occurred during the period in question, but there was no evidence that the documentation issues were identified or corrected. No further documentation was available to address the missing records.