F0842

D

Failure to Accurately Document Incontinence Care in Medical Record

Saint Petersburg, Florida Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate and complete medical records for a resident receiving incontinence care. The resident was admitted with diagnoses including need for assistance with personal care, difficulty in walking, speech and language deficits following cerebrovascular disease, and recurrent moderate major depressive disorder. A Quarterly MDS assessment documented a BIMS score of 9, indicating moderately impaired cognition. Review of the resident’s bowel and bladder task documentation showed multiple shifts on which incontinence care entries were left blank, specifically on 8/28/25 (3–11 shift), 9/8/25 (7–3 shift), 9/11/25 (11–7 shift), 9/12/25 (3–11 shift), 9/30/25 (11–7 shift), and 10/5/25 (3–11 shift). These blanks indicated that care or the absence of bowel/bladder events was not documented as required.

During an interview, the DON stated that none of the resident’s bowel and bladder tasks should be blank and that staff are expected to document “no bowel or bladder movement” if no care is needed, with all tasks completed by the end of each shift. The facility’s CNA job description requires CNAs to comply with federal and state regulations, make routine and frequent rounds, and avoid skin problems by providing timely incontinence care and repositioning. The facility’s “Documentation in Medical Record” policy, revised 6/2025, requires that each resident’s record accurately represent the resident’s experiences, with complete, accurate, factual, and timely documentation of all assessments, observations, and services, to be completed no later than the shift in which care occurred. The blank bowel and bladder task entries for this resident demonstrate noncompliance with these documentation standards.