F0842

D

Failure to Document Shift-by-Shift Monitoring After Change in Condition

Stockton, California Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that residents’ medical records accurately reflected their progress or decline following a documented change in condition. For one resident with mild chronic kidney disease, Parkinson’s disease, and dementia, a change in condition was recorded when loose, mucus-like stool was noted on 12/20/25 at 1240 using an eINTERACT Change in Condition Evaluation. Facility practice, as described by nursing staff, required monitoring and documentation every shift for 72 hours after such a change, using follow-up documentation and/or progress notes. However, only three follow-up documentation entries were completed over that 72-hour period, and only one progress note referenced monitoring for mucus in the stool, leaving six required follow-up documentation entries missing.

A second resident, admitted with type 2 diabetes mellitus and benign prostatic hyperplasia, experienced a change in condition when he complained of not feeling well and staff observed dark-colored urine and hematuria, documented on 1/2/26 at 2201 on an eINTERACT Change in Condition Evaluation. As with the first resident, the facility’s process called for monitoring and documentation every shift for three days following the change in condition. Review of the record showed only three follow-up documentation entries over the 72-hour period and one progress note describing difficulty obtaining a urine sample and low urine output, with six follow-up documentation entries missing for the required monitoring timeframe.

Interviews with licensed nurses and the DON confirmed that the facility’s expectation and practice were to complete follow-up documentation or progress notes every shift for 72 hours after a change in condition, and that the electronic record system displayed alerts indicating follow-up documentation was due every eight hours. Staff acknowledged that multiple shifts of required monitoring documentation were missing for both residents. The facility’s Charting and Documentation policy required that all changes in a resident’s medical, physical, functional, or psychosocial condition be documented in the medical record to facilitate communication among the interdisciplinary team. The missing shift-by-shift monitoring entries for both residents after their changes in condition constituted a failure to maintain medical records in accordance with this policy and accepted professional standards.