F0842

D

Incomplete Documentation of Private Aide Education and Foley Catheter Event

Maplewood, New Jersey Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records and documentation for two residents. For the first resident, who had multiple fractures, lack of coordination, cognitive impairment with a BIMS score of 9/15, and required substantial/maximal assistance with transfers, the facility allowed a private aide to be present without documented education on the resident’s care needs or limitations. The resident’s baseline care plan required one-person assistance for all ADLs, and the comprehensive care plan identified the resident as a fall risk with a prior fall and right shoulder fracture. On the night of the incident, the private aide reported to the RN that the resident fell at approximately 4:15 AM, was found standing at the foot of the bed, slid onto the floor mat, and was then picked up and placed back in bed by the aide without calling staff for assistance. Although nursing staff and the DON stated that private aides were verbally instructed not to provide hands-on care and to use the call bell for assistance, there was no documentation in the medical record that this private aide was educated on the resident’s required level of care or that the aide understood these instructions.

For the second resident, who had encephalopathy, dementia with a BIMS score of 4/15, urinary retention, diarrhea, and Non-Hodgkin lymphoma, and who had an indwelling urinary catheter, the facility failed to document a complete assessment when the resident’s Foley catheter became dislodged. The resident’s care plan included monitoring vital signs, labs, and diagnostics as ordered by the physician. A change in condition progress note created by an RN documented that the Foley catheter had dislodged and that the physician was to be notified as necessary, but the note did not include any documentation that vital signs were taken or that pain was assessed at the time of the event. The DON later stated that when a Foley catheter becomes dislodged, the nurse should assess the site, obtain vital signs, and assess for pain, and that this information should be documented in the progress notes so that everyone is aware of the resident’s status.

Additional facility policies required that private duty services support resident safety and community standards, and that all services provided to residents, including treatments, services performed, and changes in condition, be completely and accurately documented. The facility’s vital signs policy required that vital signs be taken at clinically appropriate intervals and when there were changes in a resident’s condition. Despite these policies, there was no documented evidence that the private aide for the first resident was educated on the resident’s care needs and restrictions, and there was no documentation in the second resident’s medical record that vital signs and pain were assessed and recorded when the Foley catheter became dislodged, even though an electronic communication later indicated that vital signs were at baseline and no signs of bleeding or trauma were observed. These omissions resulted in incomplete medical records for both residents.