Failure to Accurately Document CNA Turning and Repositioning Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurately documented medical records in accordance with its own policies and accepted professional standards. Facility policies required CNAs to document all care tasks, including turning and repositioning, in the electronic kiosk system every shift, regardless of shift length, and specified that kiosk documentation was mandatory and not optional. Review of one resident’s electronic medical record showed extensive gaps in CNA documentation of turn and reposition tasks across multiple dates and shifts in February and March 2026. The CNA task records did not contain initials or entries indicating that turning/repositioning was completed or refused on numerous days. The affected resident had significant medical conditions, including a stage 4 sacral pressure ulcer, hemiplegia and hemiparesis following cerebral infarction, non-pressure chronic skin ulcers, chronic embolism and thrombosis of the left femoral vein, bilateral leg contractures, and Type 2 DM. During interviews, the resident reported that CNAs did offer to turn him but that he often refused, preferring to remain on his back. A CNA familiar with the resident confirmed that he frequently refused turning despite being educated on its importance, and stated that CNAs were supposed to notify the nurse and document refusals in the kiosk under the turn/position task. The DON and the administrator both confirmed that CNA task records for turning/repositioning were missing documentation on multiple days and that CNAs were expected to document completed tasks and refusals each shift, which had not occurred for this resident.
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