Inaccurate Transfer Documentation and Incomplete Behavior Intervention Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with muscle weakness, dementia, and a history of falls, the record documented an unwitnessed fall on 12/9/25 at 5:50 PM and included an INTERACT Hospital Transfer Form dated the same day. However, the vital signs recorded on that transfer form were dated 12/3/25, six days prior to the transfer, and therefore did not reflect the resident’s condition at the time of transfer. On 1/7/26, the ADON confirmed that the INTERACT Hospital Transfer Form contained inaccurate information because the vital signs were not current at the time of transfer. For another resident with muscle weakness, visual hallucinations, and dementia, a physician order dated 12/1/25 directed staff to document the number of episodes per shift of specific target behaviors, including exit seeking, hallucinations, delusional statements, and sexually inappropriate comments, and to implement and document specified interventions such as 1:1 conversation, providing activities of choice, assisting the resident to a quiet and calm location with a snack and alternate activities, and reapproaching at a different time. Review of this resident’s behavior monitoring records from 10/1/25 to 12/31/25 showed multiple documented behavior episodes on listed dates without corresponding documentation of the ordered interventions. When the surveyor requested documentation of interventions for those episodes, no additional documentation was provided. On 1/8/26, the DON stated that while the record accurately reflected the behaviors, it did not accurately reflect the interventions used at the time the behaviors occurred.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.