Failure to Document ADL and Incontinence Care for a Resident
Penalty
Summary
Facility staff failed to document activities of daily living (ADL) assistance for one resident in accordance with accepted professional standards. Review of the electronic health record on 02/25/26 at 8:39 am for Resident #6’s ADL tasks for December 2025 and January 2026 showed multiple GNA tasks not completed in the record. On 12/24 and 12/25 during the 11 pm–7 am shift, 12/26 during the 7 am–3 pm shift, and 12/31 during the 11 pm–7 am shift, there was no documentation to verify whether the resident received personal hygiene care. On those same dates and shifts (12/24, 12/25, 12/26, and 12/31), there was also no documentation to verify that the resident was turned and repositioned. Further review of January 2026 documentation revealed additional gaps. On 01/03 during the 3 pm–11 pm shift, there was no documentation to verify that the resident was turned and repositioned. On 01/03, 01/11, and 01/18 during the 11 pm–7 am shift, there was no documentation to verify that the resident was bathed. On those same dates during the 3 pm–11 pm shift, there was no documentation to verify whether the resident had episodes of bladder or bowel incontinence or whether personal hygiene was provided. During an interview on 02/25/26 at 9:42 am, the LPN Unit Manager stated that staff were expected to document ADL care each shift, either at the time the task was completed or by the end of the shift, and that incontinence episodes should be documented. The LPN Unit Manager also stated that clinical staff are responsible for ensuring completion of documentation and that chart reviews are done the day after care is provided.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.