F0842

D

Failure to Maintain Complete and Accurate ADL Documentation in EMR

Wall, New Jersey Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The facility failed to maintain an accurate and complete medical record for a resident when required ADL documentation was missing from the electronic medical record (EMR) over multiple days and shifts. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, aphasia, apraxia, and speech disturbances. A comprehensive MDS dated 1/12/26 showed a BIMS score of 14/15, indicating the resident was cognitively intact, and documented that the resident required substantial assistance with toileting and bathing and was at risk for pressure ulcers/injuries. The resident’s care plan included a focus on risk for alteration in skin integrity, with an intervention initiated on 1/6/26 directing that the resident’s skin be observed during daily ADL care and abnormalities reported.

A review of the resident’s January 2026 task list, which the facility stated should be documented each shift, revealed no evidence of documentation for bladder continence and toilet use, bowel movement and toilet use, and hygiene on multiple specified dates and shifts. Corresponding progress notes for those dates also did not contain documentation related to these tasks. During interviews, a CNA stated that CNAs were primarily responsible for providing ADL care and were required to document all care provided in the EMR, and emphasized that documentation verified monitoring and care. The DON and LNHA confirmed that CNAs were responsible for ADL care and documentation, and that nurses and unit managers were responsible for ensuring both that appropriate care was provided and that CNAs documented the care. The facility’s Charting and Documentation policy dated July 2017 required that all services provided to residents be documented and that documentation be complete and accurate, including treatments or services performed.