F0842

D

Incomplete CNA ADL Documentation for Dependent Resident

Fall River, Massachusetts Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident who was dependent on staff for Activities of Daily Living (ADLs). Facility policy on charting and documentation, dated May 2023, required that services provided, progress toward care plan goals, changes in condition, and objective observations, treatments, or services be documented in the resident’s medical record. Resident #1, admitted in March 2024 with diagnoses including cerebral palsy, deep vein thrombosis of the left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis, and a wedge compression fracture of the fifth lumbar vertebra, had a care plan and MDS indicating dependence on staff for transfers, bed mobility, dressing, personal hygiene, bathing, grooming, toileting, and showers.

Review of this resident’s CNA ADL flow sheets for December 1–31, 2025, and January 1–31, 2026, showed multiple instances where documentation for all ADL care areas on all three shifts was left blank. In December, the 7 a.m.–3 p.m. shift had 6 days with blank ADL areas, the 3 p.m.–11 p.m. shift had 17 days with blanks, and the 11 p.m.–7 a.m. shift had 20 days with blanks. In January, the 7 a.m.–3 p.m. shift had 7 days with blanks, the 3 p.m.–11 p.m. shift had 18 days with blanks, and the 11 p.m.–7 a.m. shift had 24 days with blanks. Multiple CNAs stated in interviews that ADL documentation is done in Point of Care (POC) in the EMR and must be completed by the end of each shift. The DON acknowledged that CNA documentation had been an ongoing issue, confirmed that CNAs are expected to document all care provided by the end of every shift, and stated that daily documentation should not be incomplete or left blank.