Inaccurate Nursing Documentation Entered After Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with accepted professional standards for one resident. The resident was admitted with Parkinson’s disease, type 2 diabetes mellitus, and a stage 4 sacral pressure ulcer, and had moderately impaired cognitive skills for daily decision-making per the MDS. A Change in Condition evaluation documented that the resident developed fever, shortness of breath, and a sudden change in level of consciousness or responsiveness. Progress notes show that on 12/10/2025 at 10:10 a.m., the resident was transferred to a general acute care hospital and did not return, ultimately being discharged from the hospital. Despite the resident’s transfer and non-return, a progress note dated 12/13/2025 was entered by an LVN documenting that she received the resident resting in bed, able to make needs known, being monitored for fever, congestion, and lethargy, with no shortness of breath or acute distress, no pain, all medications given and tolerated, and that the resident was kept clean and dry with call light within reach. The note also included specific vital signs (blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation) as if the resident were present in the facility. During interview and concurrent record review, the DON confirmed that the resident had been transferred out on 12/10/2025, did not return, and that the LVN’s 12/13/2025 documentation was inaccurate and not in accordance with the facility’s nursing documentation policy, which requires concise, clear, pertinent, and accurate documentation of resident status and care given.
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