Incomplete Medical Record for Resident Following Psychiatric Consultation
Summary
The facility failed to ensure that the medical record for one resident was complete, accurate, and readily accessible, as required by federal regulations and facility policy. The resident in question had a complex medical history, including surgical aftercare, urinary tract infection, functional quadriplegia, and multiple mental health diagnoses. Upon readmission, the resident exhibited significant behavioral and cognitive changes, including self-transferring, unusual behaviors with personal and facility items, and emotional distress. The care plan included a referral to a mental health professional for trauma assessment and treatment. Despite documentation indicating that a psychiatric consultation was ordered and a telehealth appointment was conducted, there was no evidence in the clinical record that the psychiatric provider was consulted, evaluated the resident, or made any recommendations. Progress notes from staff confirmed that the telehealth visit occurred and that multiple attempts were made to obtain the visit notes from the contracted psychiatric provider. However, the psychiatric consultation records were not present in the resident's medical record at the time of review. Interviews with staff, including the CNA responsible for scheduling appointments, the Medical Records Manager, and the DON, confirmed that the psychiatric visit notes had not been received or uploaded into the electronic medical record in a timely manner. The facility did not have a policy specifying a required timeframe for uploading consult and visit notes. The absence of these records meant that the medical record was incomplete and did not fully document the services provided or the resident's response to care, as required by facility policy and federal regulation.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
A resident with multiple comorbidities, including CKD, vascular dementia, muscle wasting, and a Stage 3 pressure injury, was care planned for potential nutritional problems and required close weight monitoring. A physician ordered weekly weights for four weeks, but review of the e-chart, MAR/TAR, vitals, and nursing notes showed no documented weights or refusals during the ordered period. Staff interviews revealed that the treatment nurse and CNAs were expected to obtain and record weights, that weekly weights were required for new admissions, and that refusals should be documented, yet no such documentation existed, resulting in an incomplete and inaccurate medical record.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
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.
Failure to Document Ordered Weekly Weights for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records by not documenting physician‑ordered weekly weights for one resident. The resident was an elderly female with multiple diagnoses including hemiplegia/hemiparesis, vascular dementia, muscle wasting and atrophy, chronic kidney disease stage 2, and a Stage 3 pressure injury present on admission. Her admission MDS showed moderate cognitive impairment with a BIMS score of 11, and she was identified as being at risk for developing pressure ulcers. Her care plan identified a potential for nutritional problems related to chronic kidney disease, lung cancer, and a history of pneumonitis, with interventions that included monitoring, recording, and reporting signs and symptoms of malnutrition and significant weight loss. Record review showed that a physician order dated 03/12/26 directed that the resident be weighed weekly for four weeks on the day shift every Thursday for weight monitoring. Review of the resident’s electronic chart, including the March MAR/TAR and vitals tab, revealed that no weights were documented from the time the order was given on 03/12/26 through 03/31/26. Review of nursing progress notes for the same period showed no recorded weights and no documentation of refusals to be weighed. This lack of documentation occurred despite the facility’s policy requiring nursing staff to monitor and document resident weights in a format that permits comparison over time and to report significant weight changes to the physician and dietitian. Interviews with staff confirmed that weights were expected to be recorded and that weekly weights were required for new admissions and readmissions for the first four weeks. LVN A stated that weights should be recorded on the MAR/TAR and that she relied on the treatment nurse and CNAs to complete them, while also stating she was not responsible for verifying whether weights were taken or accurate. The DON stated that weights should be documented under the vitals tab and that refusals required a progress note. The treatment nurse (LVN B), identified as the weight loss monitoring nurse, reported she was responsible for monitoring resident weights, that some residents had weekly weights triggered in the e‑chart, and that she sometimes delegated weights to CNAs due to workload. The ADON stated that if weekly weights after admission were not completed, she would expect a nursing note explaining why, but no such notes were found for this resident, confirming the incomplete and inaccurate medical record.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
