Failure to Document ADL Care Provided to Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to provide documented evidence of care for four residents, as required by policy. The deficiency was observed through missing signatures in the Point of Care (POC) flowsheets, which are used by Certified Nursing Assistants (CNAs) to document activities of daily living (ADLs) such as personal hygiene and toileting hygiene. The missing documentation occurred across multiple dates and shifts for each resident, indicating a pattern of incomplete record-keeping. The residents involved had varying medical conditions, including dementia, diabetes, muscle weakness, anxiety, chronic obstructive pulmonary disease, acute kidney failure, Alzheimer's disease, and heart failure. Their cognitive statuses ranged from severely impaired to intact, and their required levels of assistance with ADLs varied from supervision to total dependence. Despite these needs, the POC flowsheets for each resident showed numerous instances where care was not documented as provided, with blank entries for both personal hygiene and toileting hygiene across different shifts and months. Interviews with facility staff, including a CNA, the LPN Unit Manager, and the DON, confirmed that CNAs were responsible for documenting care in the POC system and that supervisory staff were expected to ensure documentation was completed each shift. The facility's own policy required that all services provided to residents be documented in the medical record, including the date and time of care. The lack of documentation for multiple residents and shifts was therefore not in accordance with facility policy or regulatory requirements.