F0842

E

Failure to Maintain Complete and Accurate Medical Records for Behavioral and Resident-to-Resident Incidents

Zeeland, Michigan Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records and documentation of resident incidents and behaviors for multiple residents. For one resident, a risk management document dated 12/28/25 referenced an incident in which he was observed in another resident’s room lying on her bed and exposing himself, yet there was no corresponding documentation in the EMR describing the incident, no record of physician or guardian notification, and no documentation of interventions. Another resident’s EMR lacked daily behavior documentation and contained no entries regarding several resident-to-resident incidents on 10/22/25, 12/24/25, and 12/28/25, despite a behavioral health note describing a history of significant behavioral disturbances including yelling, kicking, hitting, pushing, grabbing, wandering, abusive language, threatening behavior, and sexually inappropriate behavior.

Certified Nursing Assistant behavior task documentation showed that this same resident was recorded as sexually inappropriate on 12/28/25, with additional behaviors such as wandering, abusive language, threatening behavior, grabbing, pushing, and yelling/screaming documented on 6 days within a 30‑day look‑back period. However, there was no nursing documentation or follow-up in the EMR to address or evaluate these behaviors. Nursing staff, including an LPN and a unit manager RN, reported being unaware of the sexually inappropriate behaviors and incidents, and a CNA and LPN assigned to provide 1:1 supervision to this resident did not know the reason for the supervision and could not find any explanation in the EMR. Another RN reported that when a resident’s guardian asked about an alleged incident in which this behaviorally disturbed resident reportedly grabbed the guardian’s family member by the neck on Christmas Eve, there was no incident report or EMR documentation of the event, even though the resident was later observed in the hallway tearful and talking to staff about it.

Additional documentation gaps were identified for other residents. One RN stated she completed a risk management document for a resident-to-resident incident in which one resident ended up with a scratch on her forearm after another resident walked past her, but the event was later reclassified by management as an injury of unknown origin, and the RN did not complete a witness statement. The nursing progress note for the scratched resident only documented that she was observed standing in her doorway with a skin tear to her right forearm, that the area was cleaned and a bandage applied, and that the resident stated it was from a scratch, with no further assessment or follow-up. Behavior monitoring documentation for another resident showed no behaviors recorded during the 30‑day look‑back period, including on the date of the above incident, and nursing progress notes contained no behavior or concern entries for that date. For yet another resident, there was no EMR documentation on 12/28/25 regarding an incident in which she was found sleeping in another resident’s bed while a male resident, inappropriately dressed, was standing in front of her, leaving that event entirely undocumented in the medical record.