F0842

D

Failure to Maintain Accurate and Complete Medical Records and ADL Documentation

Cincinnati, Ohio Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate and up-to-date medical records and documentation for multiple residents. For one resident with type 2 diabetes mellitus, Parkinson’s disease, and spinal stenosis, the MDS showed intact cognition and a need for assistance with ADLs, including eating, bed mobility, transfers, toileting, and bathing. However, documentation survey reports for two consecutive months showed extensive gaps, with no recorded information on bed mobility, bladder and bowel continence and movements, eating, dressing, hygiene, ambulation, transfers, wheelchair/scooter use, toileting, and behaviors. Meal and fluid intake records were blank for numerous specified dates and meals across November and December. The DON confirmed the missing ADL and meal intake documentation for this resident.

Another resident, admitted with COPD and congestive heart failure and later discharged due to death, had an MDS indicating intact cognition and a need for substantial/maximal assistance with ADLs. The progress notes for the date of death contained no documentation of the resident’s death, and the DON verified that no note describing the death could be found, despite stating she had been present when the resident died. A third resident, admitted with cerebral infarction, anemia, depression, and mood disorder, had a care plan identifying risk for constipation with interventions requiring daily recording of bowel movement patterns and monitoring for complications. The MDS indicated this resident had moderate cognitive deficits, was dependent for ADLs, and was always incontinent of bowel and bladder. Review of bowel movement records for two months revealed no documentation of bowel movements, and the DON confirmed this lack of documentation.