Failure to Document Physician Orders and Communication
Summary
The facility failed to accurately document medical records for a resident, identified as Resident #47, who was at risk of elopement and exhibited aggressive behaviors. The resident, a female with multiple diagnoses including Lewy body dementia and major depressive disorder, was admitted to the facility and later identified as an elopement risk. On a specific date, the resident attempted to elope, and the facility staff failed to document communication with the physician regarding this incident. Additionally, verbal orders from the physician to move the resident to a secured unit were not recorded in the Electronic Health Record (EHR). Interviews with facility staff revealed that the resident exhibited aggressive behaviors, such as hitting staff and attempting to leave the facility, which prompted the decision to move her to a secured unit. However, the necessary documentation, including the physician's verbal orders and the communication with the family, was not completed in a timely manner. The staff, including the Licensed Vocational Nurse (LVN) and the Social Worker (SW), acknowledged the oversight in documentation, attributing it to the hectic situation at the time. The facility's policies require that all verbal orders be documented immediately in the resident's medical record, including the date, time, and signature of the person receiving the order. Despite these policies, the documentation was not completed, which could potentially lead to residents not receiving necessary care or treatment. The facility's administration and nursing staff were aware of the documentation requirements but failed to adhere to them in this instance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
A resident with severe cognitive impairment, depression, and multiple chronic conditions alleged that a male CNA attempted a sexual act during care and became agitated and combative. An LPN assessed the resident and noted increased delusions, wrist discomfort, and a report from the resident’s son about similar behavior with UTIs, but did not document the resident’s specific statements, gestures, or emotional status. A social worker designee and HR staff also interviewed the resident, who described a man by name and clothing and complained of wrist pain, and the social worker designee reported multiple follow-up visits to assess emotional and cognitive status. However, there was no documentation in the medical record of the alleged sexual abuse incident, the detailed behaviors, or any social services follow-up, resulting in an incomplete and inaccurate record related to the abuse allegation.
Surveyors found that the facility failed to maintain complete and accurate medical records for three residents, including inconsistent documentation of a leg wound’s location by a WNP compared with nursing notes and orders, missing documentation of an annual dental visit and treatment that existed only in email despite a care plan citing dental risk, and hospice records that were not uploaded into the EMR but kept in email after the medical records position was eliminated and no policy addressed record completeness.
A resident with multiple chronic conditions was hospitalized after a fall, yet an LPN documented over several days that the resident remained in the facility, had no change in condition, was receiving skilled PT/OT/speech therapy, and had comprehensive assessments completed. The notes also stated the resident reported generalized pain and was given PRN Percocet. Review of the MAR and narcotic count sheets showed no Percocet was administered during that time, and interviews confirmed the resident was in the hospital when these entries were made. Facility policy required objective, complete, and accurate documentation, which was not met.
The facility failed to maintain accurate and consistent medical records and treatment documentation for three residents. For a newly admitted resident, no medical diagnoses were entered into the record, medication orders, or care plan at the time of review. For a resident with a prior hip fracture, physician orders for nonskid strips in front of the commode and visual reminders to use the call light remained active, and staff signed treatment sheets twice daily as if these interventions were in place, even though the DON confirmed the strips and signage had been removed when the resident stopped using the bathroom. For another resident with multiple chronic conditions and a Stage II ankle pressure ulcer, there were two conflicting active physician orders for the same ankle area—one to pad and protect a healed ulcer and another for cleansing and duoderm application—and the DON verified that one of these orders did not appear on the treatment sheet for staff documentation.
Surveyors found that three ventilator‑dependent residents with tracheostomies and complex respiratory conditions had numerous missing entries on Respiratory Treatment Records for ordered q6h ventilator checks, aerosol treatments (including albuterol, ipratropium‑albuterol, sodium chloride, and budesonide), trach assessments, trach care, inner cannula changes, oxygen administration/titration, and cough assist treatments. Care plans for these residents included oxygen therapy, trach care, and ventilator dependence with related interventions but did not specifically address the required q6h ventilator checks. The ADON, DON, RT staff, and Director of RT all verified the blanks, stated they believed treatments were done but not documented, confirmed the RTR was the only form used for ventilator checks, and acknowledged that documentation on the RTR was not accurate, despite a facility policy requiring medication error/omission reports when errors are discovered.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
Failure to Accurately Document Resident’s Allegation of Sexual Abuse and Related Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with severe cognitive impairment and multiple medical diagnoses, including stroke, dementia, depression, lung disease, and hypertension. The resident required extensive assistance of two staff for bed mobility, transfers, and ambulation, and had documented severe depression and a history of altered mood/behaviors with delusional thinking and yelling out. Despite this, the medical record contained no documentation of events related to an allegation of staff-to-resident sexual abuse that occurred on a specific date. On the morning of the alleged incident, a CNA reported to an LPN that the resident was combative when being assisted off a bedpan. When the LPN assessed the resident, the resident was very agitated and reported that a man tried to put his “thing” in her mouth, gesturing toward her own and the nurse’s private areas. The LPN acknowledged that not everything the resident said made sense but recognized the need to report the concern and informed the social worker designee. The LPN later entered a note in the medical record describing the resident as having increased delusions and false beliefs, with discomfort to the left wrist after becoming combative, and that the son stated the resident behaves this way with a UTI. However, the LPN did not document the resident’s specific statements, gestures, or emotional status from that assessment. The social worker designee reported being notified of the allegation that morning and, along with the human resources director, interviewed the resident, who was upset and yelling about a man trying to put his “thing” in her mouth, and identified a man by name and clothing description that matched the CNA. The social worker designee also noted the resident complained of right wrist pain and stated she had multiple follow-up contacts with the resident to assess emotional and cognitive status and to check in. Despite these interactions, the social worker designee confirmed that she did not document the resident’s behaviors, allegations, or any follow-up visits or psychosocial assessments in the medical record. The ADON verified that there was no documentation in the medical record of the incident, the nature of the delusions, or what led to the resident becoming combative, and that social services had made no entries for the resident during the period in question, resulting in an incomplete and inaccurate medical record related to the abuse allegation.
Incomplete and Inaccurate Medical Records for Wound, Dental, and Hospice Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for multiple residents. For one resident with severe cognitive impairment, multiple chronic conditions, and a documented skin tear to the left outer/lateral leg, the care plan and weekly non‑pressure skin grids consistently identified the wound on the left leg with specific measurements and drainage descriptions. However, a series of weekly Wound Nurse Practitioner progress notes from December through March inaccurately documented the wound as being on the right lateral leg, despite physician orders and nursing staff confirming the wound was on the left lower leg. An LPN verified during interview that the WNP documentation did not accurately reflect the actual wound location being treated. For another resident with multiple chronic diagnoses and no documented cognitive deficit, the comprehensive and quarterly MDS assessments indicated no issues with teeth, mouth or facial pain, or chewing difficulty. The care plan later identified the resident as being at risk for dental or chewing problems related to poor dental hygiene and included interventions such as arranging periodic dental consults and follow‑up dental visits. The medical record showed a refusal of dental services on one date and no documented evidence of a dental visit since admission. However, the facility’s contracted dental assistant had in fact seen the resident for an annual visit, performed a cleaning, and applied silver diamine fluoride to several teeth, with follow‑up dependent on insurance. During interview, the social worker acknowledged that this dental progress note was not in the resident’s medical record and was likely only available in email. A third resident, admitted with cerebral infarction and asthma and later enrolled in hospice, also had incomplete documentation in the medical record. Hospice documentation for this resident was not uploaded into the resident’s medical record and was instead maintained in email, as confirmed by facility staff. Further interview revealed that the medical records position had been eliminated, resulting in resident documents remaining in email and not being incorporated into the official medical record. Staff also confirmed that there was no medical records policy addressing the completeness of medical records, contributing to the absence of required hospice and dental documentation and the inaccurate wound location documentation in the residents’ charts.
Inaccurate Documentation on Hospitalized Resident’s Condition and PRN Narcotic Use
Penalty
Summary
Facility staff failed to maintain accurate and complete medical record documentation for one resident during a hospitalization period. The resident, admitted with diagnoses including Parkinson's disease, Lewy Body dementia, diabetes mellitus, and congestive heart failure, had an MDS indicating intact cognition. Nursing progress notes showed the resident was transferred to a local hospital following an overnight fall and returned to the facility via stretcher several days later. Despite this, Skilled Progress Notes completed by an LPN on three consecutive days during the hospitalization documented that the resident had no change in condition, no cognitive impairment, and was receiving skilled PT, OT, and speech therapy services. These notes also described assessments of neurological/musculoskeletal, skin, cardiac/respiratory, gastrointestinal/genitourinary status, and monitoring for medication side effects, all indicating no new or negative findings. The same Skilled Progress Notes further documented that the resident complained of generalized pain and that PRN Percocet was administered as ordered. However, review of the narcotic count sheets and the MAR for the month showed no Percocet was administered during the period in question. Interviews with the LPN who authored the notes and another LPN confirmed that the resident was hospitalized and not in the facility on the dates when these assessments and medication administrations were charted, and they could not explain why documentation was completed on an absent resident. The Administrator verified there were no discrepancies in the narcotic count sheets. Facility policy on charting and documentation required that medical record entries be objective, complete, and accurate, and made only by licensed personnel in accordance with state law and facility policy, which was not followed in this instance.
Failure to Maintain Accurate and Consistent Medical Records and Treatment Orders
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents. For one newly admitted resident, the medical record contained no listed medical diagnoses under the diagnoses category, with the medication orders, or in the care plan at the time of review. The DON confirmed that the resident’s diagnoses were not entered at admission and were only added six days later. For another resident with a history of a fall and left femur fracture, physician orders included nonskid strips on the bathroom floor in front of the commode every shift and visual reminders in the bathroom to use the call light for assistance with transfers twice a day. March and April 2026 treatment sheets showed staff signing off twice daily that these interventions were in place. However, the DON verified that this resident did not have fall strips in front of the toilet or a sign as a reminder to call for assistance, and that the facility had removed these interventions from the plan of care after the resident returned from the hospital and was no longer using the bathroom. The DON acknowledged that the corresponding physician orders were not discontinued and that nursing staff continued to document completion of treatments that were not actually in place. For another resident admitted with multiple diagnoses including cerebral infarction, protein calorie malnutrition, adjustment disorder with anxiety, anorexia, GERD, constipation, glaucoma, vascular disease, history of falling, muscle weakness, and difficulty walking, the record showed an in-house Stage II pressure ulcer to the left outer ankle. Active physician orders included one to pad and protect a healed left lateral ankle pressure ulcer twice weekly and as needed, and another to cleanse the left outer ankle and apply duoderm on specified days. The DON confirmed there were two contradicting active orders and that the pad and protect order was present in the physician orders but did not appear on the treatment sheet for staff to sign off.
Incomplete Respiratory Treatment and Ventilator Documentation for Ventilator-Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and respiratory treatment documentation for three ventilator‑dependent residents with tracheostomies. For one resident with acute respiratory failure, sepsis, heart failure, tracheostomy, and ventilator dependence, the Respiratory Treatment Record (RTR) contained numerous blanks for ordered ventilator checks scheduled every six hours and as needed across multiple days in February and March. Additional blanks were found for ordered oxygen equipment changes, nebulized sodium chloride and budesonide treatments, ipratropium‑albuterol treatments, tracheostomy assessments each shift, tracheostomy care twice daily, daily inner cannula changes, oxygen administration and monitoring, tracheostomy collar setup changes, and cough assist treatments. The resident’s care plan included oxygen therapy, tracheostomy care, and ventilator dependence with related interventions, but did not include the specific intervention for ventilator checks every six hours. A second resident, also cognitively intact and dependent in ADLs with acute respiratory failure, heart failure, tracheostomy, and ventilator dependence, had similar documentation gaps. The RTR for this resident showed missing entries for ordered ventilator checks every six hours and as needed, as well as for scheduled albuterol nebulization treatments and sodium chloride nebulization treatments. There were also blanks for ordered tracheostomy cuff assessments every shift and oxygen orders intended to maintain oxygen saturation at or above 88 percent. The resident’s care plan documented oxygen therapy, ventilator dependence, and tracheostomy care with associated interventions such as administering medications and aerosol treatments as ordered, monitoring oxygen saturation, and assessing for signs of hypoxia, but did not address the specific requirement for ventilator checks every six hours. The third resident, with extensive diagnoses including acute and chronic respiratory failure, CHF, COPD, interstitial lung disease, dysphagia, myasthenia gravis, non‑Hodgkin lymphoma, dementia, and CKD, and who had a tracheostomy and was ventilator‑dependent, also had incomplete documentation. For this resident, the RTR contained multiple blanks for ordered ventilator checks every six hours and as needed, both before and after a hospital discharge and readmission. There were additional blanks for ordered albuterol nebulization and later ipratropium‑albuterol aerosol treatments, as well as for oxygen titration orders to maintain oxygen saturation of 88 percent or greater every shift. The care plan for this resident identified tracheostomy and ventilator dependence with interventions including aerosol treatments as ordered, suctioning as necessary, and monitoring and documenting respiratory status every shift. Interviews with the ADON and a respiratory therapist confirmed that an RT was always present in the facility and that RT staff were expected to document on the RTR when orders were completed, omitted, refused, or not completed for any reason. They verified the blanks on the RTRs for all three residents and stated they believed the orders were completed but not documented, and confirmed there was no other documentation used for ventilator checks beyond the RTR. The DON also verified the presence of blanks on the RTRs for ventilator checks, aerosol treatments, tracheostomy assessments, and oxygen orders, and stated that a medication error form should have been completed for any omitted treatment or medication. The Director of Respiratory Therapy acknowledged noticing the blanks, stated that RT staff were not used to documenting on the RTR and that she herself had not documented at times, and confirmed that the RTR documentation was not accurate. Facility policies on medication errors and invasive mechanical ventilation were reviewed; the medication error policy required completion of a medication error/omission report when an error was discovered, and the invasive mechanical ventilation policy did not address ventilator checks or documentation requirements on the RTR.
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