Failure to Consistently Document ADL Bladder Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to consistently document Activities of Daily Living (ADLs), specifically bladder care, for two residents. For one resident with spinal stenosis and Parkinson’s disease and a BIMS score of 8/15 indicating moderate cognitive impairment, review of the December 2025 Documentation Survey Report (POC) showed blank entries for bladder documentation on multiple shifts and dates, indicating the task was not documented as completed. For another resident with chronic pulmonary embolism and type 2 diabetes mellitus and a BIMS score of 15/15 indicating intact cognition, the December 2025 POC similarly contained numerous blank bladder documentation entries across day, evening, and night shifts, again indicating the task was not documented as completed. During interviews, a CNA stated that ADL care is documented on the POC and that the expectation is to complete documentation within two hours before the end of the shift, acknowledging that documentation serves as proof of care provided. An LPN stated that all documentation should be completed before staff leave the facility. When presented with the POC records for both residents, the DON acknowledged the blanks and stated that staff are expected to document accurately according to the numerical log and to complete ADL logs in their entirety so the facility can know and perform residents’ needs and expectations. Review of the facility’s ADL policy, implemented 09/01/24, stated that residents unable to carry out ADLs will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene, which the facility failed to follow as evidenced by the incomplete ADL documentation.
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