Two residents’ medical records were not maintained in a complete and accurate manner. For one resident with multiple complex conditions and total dependence for ADLs, the EHR documented that the resident left for a procedure but contained no follow-up notes on the resident’s return, new devices, status, or orders, and several 72-hour readmission entries were left blank until a later NP note about a new infection. For another resident with a history of falls and a left femur fracture, the care plan and fall log reflected multiple falls and fall-prevention interventions, but the EMR lacked any documentation of a fall that resulted in injury or a related physical assessment, even though a subsequent progress note described bruising, swelling, and physician notification.
Two residents with physician orders for Foley catheter care every shift reported that catheter care was not performed, while their treatment administration records showed the wound nurse’s initials indicating the care was completed. The assigned RNs stated that night shift or other nurses were responsible for catheter care and that they did not perform it, and the wound nurse confirmed she did not provide Foley catheter care on the documented days, despite having initialed the TARs. The DON stated that nurses are expected to follow physician orders and document accordingly, and CMS guidance cited in the report stresses the need for complete and accurate documentation of services.
A resident with a tracheostomy on high-flow O2 died after the trach became dislodged, and facility documentation of the event was inaccurate, incomplete, and inconsistent. An LPN noted the resident manipulating trach oxygen tubing but did not document any intervention to prevent dislodgement. Later, an RT documented reinserting the trach, stating the resident had a pulse and labored breathing while CPR was charted as occurring, and 911 times in the notes conflicted with EMS records. Paramedics reported finding the resident pulseless and apneic, with staff attempting trach reinsertion, and noted significant facial and tongue swelling that prevented intubation. The RT gave multiple, changing accounts about swelling and trach reinsertion and admitted omitting key clinical details, while a nurse consultant stated that the LPN had not actually performed CPR despite charting that she had. These discrepancies show the facility failed to maintain accurate, complete medical records for the incident.
The facility failed to maintain accurate and complete electronic clinical records for multiple residents. One cognitively intact resident’s care plan did not reflect a history of making false allegations, and his record lacked documentation of departure and return from therapeutic leave, including whether medications were provided, while the MAR conflicted with the resident’s report of receiving morning medications after elevated BP was noted. In addition, another cognitively intact resident’s record contained no documentation of a physical altercation with his roommate, even though an incident report described a verbal dispute that became physical, involved police response, and resulted in court fines for both residents.
A resident on neuro checks after a fall with head trauma had missing post-fall neuro documentation in the electronic record. When a Neuro/Head Trauma Assessment form was produced, the entries were all in the same handwriting even though different staff initials were used, and the DON and Administrator agreed the record appeared to be falsified.
The facility failed to maintain complete and accurate medical records when staff did not document multiple incidents and allegations of verbal abuse between two roommates. One resident reported being yelled at and called offensive names by her roommate and expressed fear of further retaliation, while a CNA and a psychotherapist/LCSW both observed or learned of loud, upsetting verbal altercations and reported them to the Administrator/Abuse Prevention Coordinator and nursing staff. Despite these reports and the separation of the roommates, there was no timely documentation of the abuse allegations, staff notifications, or resident monitoring in either resident’s chart, and only late backdated social service notes were entered, contrary to facility policies requiring documentation of all incidents, allegations of abuse, and changes in condition.
A resident with a history of emphysema and prior smoking had conflicting nicotine-related information between hospital records, facility assessments, and the face sheet. Hospital documentation and a CT lung screening indicated nicotine dependence in remission, while the facility’s social history recorded no nicotine/tobacco history or current use, and the medical record listed an active nicotine dependence diagnosis with inconsistent onset dates. The resident, who reported having quit smoking and was concerned about assisted living acceptance, identified the discrepancy. The MDS coordinator and DON reported that diagnoses are entered from hospital records and updated when aware of new information, but they were not aware of all outside appointments and records, leading to the nicotine diagnosis being coded as dependence instead of remission and resulting in an incomplete and inaccurate medical record.
Two residents’ medical records were not accurately maintained. One resident experienced a verbal altercation with another resident in the dining room that led to crying and emotional distress, but the incident and subsequent emotional response were not documented or monitored in the medical record, despite the resident having depression and being cognitively intact. Another cognitively intact resident’s MDS inaccurately indicated no obvious cavities or broken teeth, while the care plan and direct observation showed poor dentition with multiple black, brown, broken, and chipped teeth and a reported plan for full dental extractions and dentures.
A resident with alcoholism and diabetes left the facility after a short stay and did not return, and staff failed to maintain complete and accurate documentation of the events surrounding the departure. The resident’s record lacked an AMA form, there was no sign-out entry identifying who took the resident out, and nursing staff did not document that the resident was missing at the time of a scheduled blood sugar check, that the CNA reported seeing the resident’s daughter take the resident out, or that the PM RN later confirmed with family that the resident refused to return. These omissions occurred despite facility policy requiring organized, accurate, and complete written records for each resident.
A resident with a PEG tube for dysphagia had the tube dislodged and was sent to the ED, but the facility failed to document the incident, the resident’s departure, or related clinical details in the medical record. A CNA reported finding the tube on the floor, obtaining normal VS, and preparing the resident for transport after notifying an RN. The RN reported managing multiple emergencies and acknowledged that documentation may not have been completed. Staff interviews indicated that an order for transfer, progress notes, and documentation of physician and family notification should have been present, in contrast to facility policy requiring complete, accurate, and timely documentation of resident care and events.
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