Incomplete and Inaccurate Documentation of ADLs and Interventions
Penalty
Summary
The facility failed to maintain complete and accurate documentation of activities of daily living (ADLs) and interventions for three residents with diagnoses including dementia, repeated falls, hypertension, and diabetes. For one resident, documentation indicated that body pillows were in place to prevent rolling out of bed even after the intervention had been discontinued and the pillows were no longer available. Additionally, there were multiple instances where documentation for showers, dressing, personal hygiene, and eating was missing for all three residents over several dates. Interviews with the Director of Nursing, Nursing Home Administrator, and Assistant Director of Nursing confirmed the inaccuracies and omissions in the clinical records. Facility policies required that all services provided to residents be documented objectively, completely, and accurately, but these requirements were not met for the residents reviewed.