Incomplete Documentation of Resident Care and Transfers
Penalty
Summary
The facility failed to consistently document and maintain complete medical records regarding toileting, bowel and bladder continence, and incontinent care for two residents. For one resident with diagnoses including type II diabetes, osteoarthritis, and hypertension, documentation was missing in the daily shift records and progress notes for multiple dates in February. The resident required substantial assistance with toileting, as indicated by the Minimum Data Set (MDS) and care plan, but there were gaps in the records for bladder and bowel continence and bowel movements across several shifts. Another resident, admitted with conditions such as cerebral infarction, heart failure, and mobility issues, also had incomplete documentation in October. This resident required partial assistance with toileting transfer and was fully dependent in toileting hygiene. The records lacked documentation for bladder and bowel continence and bowel movements for a specific evening shift. Additionally, after an incident where this resident was sent out of the facility for further evaluation following an allegation of a fall, the medical record did not include the time of transfer, and there was no documentation indicating when the resident left the facility, despite a note confirming the resident's return. Interviews with staff, including an LPN, Unit Manager, DON, and a CNA, confirmed that CNAs were responsible for documenting incontinent care in the electronic medical record and that documentation was important for tracking care and preventing skin issues. The DON and other staff acknowledged the presence of blanks in the documentation and emphasized that all services provided should be documented completely and accurately, as required by facility policy.