Inaccurate Documentation of Vital Signs for Absent Resident
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record by documenting vital signs for a date when the resident was not present in the facility. Specifically, the medical record for one resident showed that vital signs were obtained on 6/12/25, despite the resident having been transferred to an acute care hospital on 6/10/25 and remaining there thereafter. This discrepancy was confirmed during a review of the closed medical record and an interview with the Director of Nursing (DON), who verified that the resident was not in the facility on the date the vital signs were recorded. The inaccurate documentation included specific vital sign measurements such as blood pressure, respirations, pulse, and oxygen saturation, all recorded as if obtained in the facility after the resident's transfer. The error was identified during a closed record review initiated several days after the resident's transfer, and the DON acknowledged the inaccuracy in the resident's medical record. No information was provided regarding the resident's medical history or condition at the time of the deficiency beyond the fact that the transfer to the hospital was due to lethargy.
Plan Of Correction
F-842 Resident Records - identifiable information Corrective Action Initiated for Resident/ On 7/3/25, the inaccurate entry for Resident 94's vital signs dated 6/12/25 was identified and corrected by marking the documentation as an error in the electronic medical record (EMR) with appropriate notation by DON. CNA who made the error in documentation was given 1:1 training by the DSD on 6/18/25. A late entry progress note was added by DON on 7/3/25 clarifying that Resident 94 was hospitalized during that period and that the vital signs were entered in error RT #94 was discharged on 6/17/25. How Potential Other Residents Were Identified and Corrective Action Taken An audit was conducted by medical records/designee on 7/3/25 of residents who were transferred to acute care hospitals between 6/3/25 to 7/3/25 to ensure no other inaccurate entries were made post-discharge. 17 residents were checked with 1 resident noted with blood pressure taken after he was transferred to the hospital. Vital sign was struck out and progress note done on 7/3/25. 1:1 training with the charge nurse who made the error was done on 7/3/25. Measures/Systemic Changes Initiated to Prevent Future Recurrence On 6/20/25, nursing staff received re-education by the DSD on proper documentation protocols, including: verifying resident presence before documentation, correct use of EMR templates, and discontinuing charting once a resident is discharged or transferred. Medical Records will audit each discharge record to ensure documentation entries are accurate -- findings will be submitted to DON for follow-up and resolution. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The MRD will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/3/25