Incomplete POLST Form for Resident
Summary
The facility failed to ensure accurate and complete medical records for one of the nine sampled residents, specifically regarding the Physician Orders for Life-Sustaining Treatment (POLST) form for a resident. The POLST form, which is crucial for outlining a resident's end-of-life care preferences, was found to be incomplete as Section B, which details medical interventions, was left unmarked. This section is essential for indicating whether the resident desires full treatment, selective treatment, or comfort-focused treatment. The omission was identified during a review of the resident's records, and it was acknowledged by the Infection Prevention Nurse that the POLST should have been completed to reflect the resident's wishes accurately. The resident in question was admitted to the facility with multiple serious health conditions, including heart failure, kidney failure, hemiplegia, hemiparesis, dysphagia, and pneumonia. Despite these conditions, the resident was assessed as cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15. The Admission Nurse confirmed the importance of a complete POLST form for guiding care during emergencies and ensuring that the resident's end-of-life care preferences are respected. The facility's job description for medical records emphasizes the need for accuracy and completeness in clinical documentation, which was not upheld in this instance.
Penalty
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A resident with a Stage 4 pressure ulcer and a physician’s order for Tramadol 50 mg to be given on the day shift 30 minutes before wound care had multiple missing and unexplained entries on the MAR, even though the Treatment Record showed that wound care was performed daily. On several days, there were no nurse signatures for the ordered Tramadol, and on other days the MAR was marked as “out of parameters” without any supporting progress notes. The wound care nurse reported relying on the MAR to confirm that pain medication was given before she performed wound care, and the DON stated that nurses are expected to follow physician orders and document refusals, but the record did not contain adequate documentation to demonstrate proper administration or explanation of the ordered pain medication.
The facility failed to maintain complete and accurate medical records for multiple residents, including missing and delayed documentation of a fall and hospital transfer, incomplete shower and meal intake records, undocumented bowel movements despite a PRN laxative order, and missing treatment administration entries for ordered tracheostomy care and inner cannula changes. Staff, including LPNs, an RN, and the DON, confirmed that assessments, investigations, and routine care were either not documented, left blank, or not signed in the EMR or on treatment records, contrary to the facility’s own documentation policy.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
Surveyors found that staff failed to accurately document a resident’s ongoing purple discoloration on the buttocks despite physician orders and a care plan requiring weekly skin assessments and documentation of abnormal findings, and despite prior hospital documentation of the discoloration. In addition, staff did not accurately document administration of calcitonin-salmon nasal spray for another resident, recording doses as given to the wrong nostril on multiple occasions, even though the DON reported the medication was being administered as ordered. These practices were inconsistent with the facility’s documentation policy requiring accurate, organized entries for skin assessments and medication administration.
The facility failed to maintain complete and accurate documentation of ordered wound treatments and scheduled showers for multiple residents with complex medical conditions, including cerebral palsy, chronic respiratory failure, COPD, multiple sclerosis, diabetes, quadriplegia, and spina bifida. Physician-ordered wound dressings to areas such as the ischium, coccyx, and sacrum, as well as scheduled bathing tasks on specific shifts, were frequently not recorded on treatment and ADL records, despite facility policies requiring detailed charting of all procedures and hygiene care. The NHA in training confirmed that these wound dressings and showers were required to be completed as ordered and documented when provided.
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
Incomplete Documentation of Ordered Pain Medication Prior to Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of complete and accurately documented medical records related to pain medication administration prior to wound care for one resident with a pressure ulcer. The resident was admitted with diagnoses including peripheral vascular disease and had a care plan for a Stage 4 pressure ulcer that included administering medications and treatments as ordered. A significant change MDS indicated the resident had no cognitive impairment, required setup/cleanup assistance for eating and oral hygiene, had a Stage 4 pressure ulcer, received a scheduled pain medication regimen, and experienced moderate, occasional pain. A physician’s order dated 04/23/2026 directed that Tramadol 50 mg be given orally on the day shift for pain, 30 minutes before wound care. Review of the May 2026 Medication Administration Record (MAR) showed missing nurse signatures for the ordered Tramadol on multiple dates (05/02, 05/03, 05/09, and 05/10), despite the Treatment Record reflecting that wound care was performed daily on the day shift. On additional dates (05/04–05/06 and 05/11), the MAR entries for Tramadol were signed with code “4” indicating “out of parameters” by a registered nurse, but there were no associated progress notes explaining these entries. The wound care nurse reported that the resident had an order for Tramadol prior to wound care, that she performs wound care Monday through Friday, and that the floor nurse performs it on weekends, and she stated she checks the MAR to ensure the medication was given. The DON stated that nurses are to follow physician orders and document if a resident refuses medication. The facility’s pressure ulcer/skin breakdown protocol required pain assessment and documentation, but the medical record lacked adequate documentation to show that the ordered pain medication was administered or appropriately addressed on the identified dates.
Plan Of Correction
The facility continues to ensure that resident's medical records are complete and accurately documented. IMMEDIATE CORRECTIVE ACTION Resident #62 was assessed by Director of Nursing upon notification of surveyor and resident #62 did not have any adverse outcome related to the alleged deficient practice on 5/13/26. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. Director of Nursing and/or designee conducted a comprehensive chart audit to ensure that residents with pain medications were accurately documented on EMAR on 5/15/26. No residents were adversely affected by the alleged deficient practice. SYSTEMATIC CHANGES The Director of Nursing and/or designee initiated ongoing in-service education with clinical staff on standards of accurate medication administration documentation with emphasis on accurate documentation of Pain Medication Refusal. MONITORING Nursing Supervisor and/or designee will conduct random observation and/or audits to ensure accurate documentation of pain medication administration and refusal, 5 days a week for 1 month, then weekly for 3 months. The Director of Nursing and/or designee will report findings of observation/audits to the quality assurance committee monthly for 4 months to ensure continued substantial compliance is achieved and maintained.
Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and timely medical records for multiple residents, as required by regulation. For one resident with acute osteomyelitis of the right ankle and foot, type II diabetes, and dementia, the care plan identified a risk for fall-related injury. A nursing note documented that the resident went to the hospital on a specific evening but did not include any additional information. An electronic change-in-condition assessment for that date was opened but left blank, and the fall investigation was opened but not signed until weeks later. The DON stated that the paper fall investigation used for QAPI was not considered part of the medical record. Another resident, admitted with dysphagia and developmental issues, had multiple missing entries in shower documentation over several weeks. The DON confirmed that shower documentation was missing on numerous identified dates. The same resident’s meal intake records also contained multiple gaps for specific meals and days, which the DON likewise confirmed as missing. The resident reported that she did receive her showers but that staff did not assist her with shaving, while the record did not consistently reflect the provision of showers or meal intake. A third resident with dementia, difficulty walking, and low back pain had bowel movement (BM) records showing no documented BM for a seven-day period and a separate five-day period. The resident had an active PRN order for Bisacodyl 10 mg suppository for constipation, in place since admission, but the MARs for the relevant months showed no administration of the medication during those intervals. An LPN confirmed the absence of documented BMs and the lack of recorded Bisacodyl administration, and later acknowledged that some BMs were not entered into the EMR. The resident’s daughter reported that the resident’s bowels moved regularly and that the family monitored this closely, expressing confidence that BMs occurred during the periods where none were documented. A fourth resident with chronic respiratory failure with hypoxia, COPD, asthma, chronic pulmonary edema, and a tracheostomy had physician orders for tracheostomy care and inner cannula cleaning every shift. Review of the treatment administration records for a given month revealed multiple shifts with missing nurse initials where tracheostomy care should have been documented. An RN confirmed that the TAR did not provide documented evidence that tracheostomy care was completed on those dates and explained that on those shifts a medication technician was assigned to the hall, and a nurse from another hall would have performed the care but failed to sign it. The facility’s “Documentation Expectations” policy required healthcare personnel to complete documentation in the medical record using accepted principles and for licensed nurses to audit documentation for completeness and accuracy, which was not met in these instances.
Plan Of Correction
1. On 5/6/26 Resident #9 was assessed by Director of Nursing and shows no ill effect related to the lack of documentation for tracheostomy care. On 5/6/26 Resident #12 was assessed by Director of Nursing and shows no ill effect related to going greater than 3 days with no bowel movement documented. On 4/15/26 Resident #76 received a shower by the STNA. On 5/6/26 the Director of Nursing reviewed Resident #76 and determined there was no ill effect related to the missing meal documentation and the resident's weight remains stable. Resident #86's fall investigation was completed on 4/28/26 the Interdisciplinary Team. A new intervention of a reaching device was implemented and placed on the resident's care plan. The reaching device was implemented on 3/25/26 by the licensed nurse. The care plan was updated on 4/9/26 by the Director of Nursing to include intervention of a reaching device. 2. Like Residents are identified as residents who utilize a tracheostomy. An audit will be completed by the Director of Nursing or designee utilizing the Tracheostomy Care Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure tracheostomy care is documented in the medical record. This audit will look back to 5/1/26. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who go greater than 3 days with no bowel movement documented in the medical record. An audit will be completed by the Director of Nursing or designee utilizing the Change in Condition Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, to ensure appropriate documentation is completed when a resident goes greater than 3 days with no bowel movement. This audit will look back to 5/1/26. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who need assistance with showering. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers completed and documented in the medical record. This audit will look back to 5/1/26. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls for the past 30 days will be completed by the Director of Nursing or designee to ensure fall documentation is entered into the residents' medical record post fall. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Tracheostomy tube cannula and stoma care policy to include documenting the procedure. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on Notification of Change Policy to include follow up documentation related to a resident with no bowel movement documented within 3 days. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include documentation of bathing. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Food Acceptance Policy to include documenting meal intake in POC. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on the Fall Management Policy to include fall documentation entered into the residents' medical record post fall. This education will be completed on or before 5/13/26. 4. Utilizing the Tracheostomy Care Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of residents with tracheostomies to ensure tracheostomy care is documented in the medical record. This audit will be completed for all residents who have a tracheostomy weekly for 4 weeks, beginning 5/14/26 to ensure tracheostomy care is documented in the medical record. Noncompliance noted during audits will be corrected with tracheostomy care documented in the medical record. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Change in Condition Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of residents with no bowel movement documented for greater than 3 days to ensure appropriate documentation is completed. This audit will be completed for 4-6 residents weekly for 4 weeks, beginning 5/14/26 to ensure appropriate documentation is completed when a resident goes greater than 3 days with no bowel movement. Noncompliance noted during the audits will be corrected with appropriate documentation completed. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of resident showers to ensure that showers are completed and documented in the medical record. This audit will be completed for 4-6 residents weekly for 4 weeks, beginning 5/14/26 to ensure that showers completed and documented in the medical record. Noncompliance noted during audits will be corrected with showers completed and documented in the medical record. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of residents experiencing a fall within the last 7 days ensure fall documentation is entered into the residents' medical record post fall. This will be completed weekly for 4 weeks, beginning 5/14/26 to ensure fall documentation is entered into the residents' medical record post fall. Noncompliance noted from the audits will be corrected with documentation entered into the residents' medical record post fall. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Accurately Document Skin Assessments and Medication Administration
Penalty
Summary
The facility failed to ensure accurate and timely documentation of skin assessments for one resident. During an observation of incontinence care, the resident was noted to have a large purple discoloration on both buttocks, and barrier cream was applied. The resident’s diagnoses included diabetes mellitus, hemiplegia, and a left below-knee amputation, and the MDS indicated the resident was cognitively intact and dependent on staff for several ADLs. Physician orders and the skin integrity care plan required weekly skin assessments, documentation of skin condition, and notification of the MD for abnormal findings. A hospital after-visit assessment documented a non-blanchable purple discoloration on the buttocks, but subsequent admission and weekly skin observations, including the most recent one, documented no skin discolorations. The RN and Wound Nurse later indicated the resident had purple discoloration on the buttocks since admission, but staff had not documented its presence. The facility also failed to ensure accurate documentation of medication administration for another resident receiving calcitonin-salmon nasal spray. The resident had chronic obstructive pulmonary disease and required setup assistance for eating. Physician orders directed calcitonin-salmon spray to be administered to alternating nostrils on different days. A pharmacy consult noted staff were not giving calcitonin spray as ordered and recommended staff education on proper administration. Review of the eMAR showed that staff documented administering the spray to the left nostril on some days when the order was for the right nostril, and to the right nostril on some days when the order was for the left nostril. The DON stated that staff were administering the calcitonin spray as ordered but were not documenting it correctly. The facility’s documentation policy required accurate, organized documentation of all resident information, including weekly skin and vital sign assessments and wound management entries.
Incomplete Documentation of Wound Care and Bathing
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate documentation of wound treatments and bathing in accordance with its own policies and accepted professional standards. Facility policies on Activities of Daily Living and Charting and Documentation require that residents who cannot perform ADLs independently receive appropriate hygiene care, and that all procedures and treatments be documented with date, time, and the signature and title of the person providing care. For one resident with cerebral palsy, chronic respiratory failure, and a gastrostomy, physician orders required wound dressings to the right ischium every morning and at bedtime, but the March 2026 treatment record lacked documentation of multiple ordered dressing changes. The same resident’s bathing task, scheduled for specific days on day shift, also lacked documentation that baths were provided on several scheduled dates. Additional residents were affected by similar documentation gaps. One resident with hypertension, COPD, and lumbar spine fusion had an order for a daily coccyx wound dressing on day shift, but the March 2026 treatment record lacked documentation of numerous dressing changes, and the bathing task, scheduled for specific evenings, lacked documentation of several baths. Another resident with chronic respiratory failure, multiple sclerosis, and hypertension had missing documentation for several scheduled baths. A resident with diabetes and quadriplegia had multiple scheduled baths without corresponding documentation. A fifth resident with spina bifida, anxiety, and diabetes had physician orders for daily wound dressings to the left ischium and right sacrum, but the March 2026 treatment record lacked documentation of several of these treatments. In an interview, the Nursing Home Administrator in training confirmed that the clinical records for all five residents did not contain complete documentation of wound dressing changes and/or showers and acknowledged that these should be done as ordered and documented when completed.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
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