F0842

E

Inaccurate ADL and Behavior Documentation for Dependent, Non-Ambulatory Residents

Pensacola, Florida Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves inaccurate and inconsistent medical record documentation for three residents, failing to reflect their actual functional status and behaviors. For one resident diagnosed with paraplegia, ADL documentation showed that he ambulated 150 feet independently or with varying levels of assistance and transferred from bed to chair independently or with supervision on multiple dates. However, observations on two consecutive days showed that he was bed bound with no active movement in his lower extremities, and both an LPN and a CNA confirmed he was paralyzed and unable to walk or transfer independently, stating that the documented entries would be impossible.

For another resident, CNA flow sheets over a specified period documented independence with toilet and bed transfers, independence with lower body dressing, call light within reach, and fluids provided while at the hospital, while the resident’s care plan indicated total staff assistance. Observation showed this resident lying on her back with limited body movements, and a CNA later stated she required total care, had not been able to turn from side to side for several years, and required assistance with feeding. A third resident’s CNA flow sheets documented independence with toilet transfer and no behaviors, despite nursing notes on multiple dates describing the resident as upset, yelling, and screaming, and a care plan indicating a self-care deficit with total staff assistance for toileting, hygiene, and transfers, and that the resident was non-ambulatory. Observation showed this resident sliding down in bed and unable to reposition without assistance, and a CNA stated he required total care, while also explaining that behaviors were reported to the nurse and documented in a behavior flow sheet.