F0842

E

Failure to Maintain Complete CNA Flow Sheet Documentation for Multiple Residents

Lincoln, Massachusetts Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The facility failed to maintain complete and accurate medical records when CNA flow sheets documenting the provision of care were left blank for multiple days and shifts for three residents. Facility policy on Charting and Documentation, revised 07/2017, required that all services provided to residents, progress toward care plan goals, and any changes in residents' conditions be documented in the medical record. For a resident admitted in November 2025 with diagnoses including Type 2 Diabetes Mellitus, Hypertension, and Urinary Tract Infection, review of CNA flow sheets for December 2025 showed multiple dates where all three shifts (day, evening, and night) were left blank, including 12/02, 12/04 through 12/08, 12/11, 12/13, and 12/14.

A second resident admitted in December 2025 with diagnoses including status post fall and a right lower leg infection had CNA flow sheets for January 2026 with no documentation on several dates across all shifts, specifically 01/02 through 01/04, 01/07, 01/08, 01/12, and 01/13. A third resident admitted in December 2023 with dementia and anxiety had extensive gaps in CNA flow sheet documentation for December 2025 and January 2026, with multiple consecutive days and shifts left blank, including large portions of early, mid, and late December and early to mid-January. During interview, a CNA stated they are supposed to document care on the electronic flow sheet once completed and noted there is no electronic alert if documentation is not done. In a separate interview, the DON stated CNAs were supposed to complete their flow sheets at the end of every shift and acknowledged there were several missing days of CNA documentation for the three residents.