F0842

D

Incomplete ADL and Meal Documentation for Dependent, Incontinent Resident

Pinellas Park, Florida Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to maintain complete and accurate medical records for a resident with multiple diagnoses, including Parkinson's disease, sarcopenia, cognitive communication deficit, dementia, history of TIA, and cerebral infarction without residual deficits. The resident was admitted and discharged within a few days, and review of the toileting task documentation for that period showed no recorded incontinence care during 8 out of 10 opportunities. Review of the nutrition/eating task documentation for the same period showed no record that the resident received meals during 7 out of 9 opportunities. There were no documented refusals of care or meals.

Staff interviewed on later dates did not remember the resident due to the short stay and could not describe the care provided. The DON stated she was not familiar with the resident and confirmed that documentation should verify whether care was provided or refused, and that there was no reason for care opportunities to be left blank. The resident’s MDS showed severe cognitive impairment (BIMS score of 04), dependence for toileting hygiene, and always incontinent for bowel and bladder. The care plan identified potential/actual skin integrity impairment related to decreased cognition, mobility, incontinence, pain, and weakness, with interventions to keep skin clean and dry. Facility policies on incontinence, ADLs, and serving meals required provision of appropriate toileting and nutritional care, but the facility did not provide a policy on documentation, and the existing record did not allow determination of whether incontinence care and meals were actually provided.