What should be documented if a resident deviates from the care plan during an activity?

• A. The deviation is ignored.
• B. The deviation is noted in passing conversation.
• C. The deviation is documented with time, what happened, who observed, and any steps taken; inform nurse.
• D. The deviation is corrected spontaneously by CNA without notifying nurse.

Answer: (C)

Documenting any deviations from the care plan is essential for safety and continuity of care. When a resident deviates during an activity, record the exact time, what happened, who observed it, and any steps you took to address the situation. Then inform the nurse so the care plan can be reviewed and adjusted if needed. This creates an clear, traceable record that helps the rest of the care team understand the situation, ensures accountability, and supports appropriate follow-up.

Documentation should be factual and objective, not opinions or guesses, and should be done promptly rather than left to memory. By keeping a proper record, you help prevent repeats of the same issue and enable timely, coordinated care.