Failure to Accurately Document Resident Assessment and Physician Communication During Change in Condition
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical documentation in accordance with its own policy and accepted professional standards for one resident. The resident, an older male with pulmonary fibrosis, chronic hypoxic hypercapnic respiratory failure, and COPD, was admitted from the hospital with ongoing respiratory issues, including shortness of breath, worsening hypoxia, and confusion. On admission, he had orders for continuous oxygen at 2–6 L/min via nasal cannula with oxygen saturation monitoring each shift, and scheduled Ipratropium-Albuterol inhalation for shortness of breath. An IDT nursing note documented that he was admitted following episodes of altered mental status, hypoxia, pulmonary fibrosis, and COPD, and that he was on 4–6 L/min of oxygen. On the day of admission, the resident experienced a change in condition with worsening hypoxia. An SBAR form documented that his oxygen saturation was 74% via nasal cannula and that his son reported the resident was not receiving enough oxygen through the concentrator and requested that he be sent out. An IDT nursing note by an LVN recorded that the resident complained of hypoxia and shortness of breath, with vital signs including BP 157/83, HR 122, respirations 30, and oxygen at 6 L/min, and that the physician was notified and ordered transfer to the ER via EMS, with the resident transferred to the hospital and a family member at bedside. However, during interview, this LVN stated she had assessed the resident when he was yelling that he could not breathe and arranged transfer to the ER, but she acknowledged she had not documented her assessment in the clinical record on that day and had not documented that the family member was in the room when the resident was transported. Another LVN reported that she made two telephone calls to the resident’s attending physician on the day of admission: one to confirm medication orders upon admission and a second to report that the resident had been sent to the hospital via EMS due to a change in condition. She stated that licensed staff had been trained to document in the clinical record when they called the physician to obtain orders or report changes in condition, but she did not document either of these calls in the resident’s record, citing multiple admissions that day and lack of time. The DON confirmed that licensed staff were trained to document resident assessments and physician or NP communications in the electronic record. Review of the facility’s Clinical Documentation policy showed that documentation was to be accurate, timely, reflective of care provided, and completed as close to the time of care as possible, including documentation of assessments and exceptions when care does not occur as planned, which was not followed in this case.
Penalty
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Incomplete and inconsistent AD and POLST documentation was found for multiple residents. One resident’s AD and POLST conflicted on artificial nutrition and hydration, another resident’s AD called for comfort care only while the POLST selected CPR and full treatments, and other residents’ POLSTs documented “no decision made” or that an AD was not available despite ADs being present. Staff interviews showed an LN had marked the AD-review section without confirming the AD, the RA was not comparing ADs with POLSTs, and the DON said review responsibilities were shared among staff.
Incomplete and inconsistent documentation was found for a resident’s bathing care and for multiple residents’ skin-related treatments. Shower/bath records did not match the EMR and lacked entries for several days, with no documentation of physician or resident representative notification for refusals. Wound care, dressing changes, and lidocaine patch documentation were also missing or inconsistent with observations, and one resident was observed without ordered compression stockings.
Incomplete and inaccurate resident clinical documentation: A resident with hemiplegia, DM, and dementia had inconsistent behavior monitoring and a new order for a Wanderguard, but no progress note was entered on the day of the order. The chart also included a physician note stating the resident had been found wandering outside on the curb, which the NHA later said was inaccurate; the facility’s review found the statement was entered based on word of mouth staff information and that no elopement occurred.
Incomplete and inaccurate resident record documentation: Surveyors found that several resident records did not match the documented care or resident directives. One resident’s POLST left the Health Care Agent section blank despite an advance directive naming an agent, another resident’s opioid overdose monitoring entries used Y/YES in a way that did not align with the order’s required documentation, an IV antibiotic dose was not documented as given, and a physician progress note was dated after a resident had already been transferred to the hospital.
Falsified vital signs documented in a resident record. An agency RN charted pulse, BP, and respirations for a resident with multiple serious diagnoses, but security footage and DON review showed no vitals were taken during the shift because the RN did not have the vital sign machine. The RN later confirmed she did not take any vital signs despite documenting them.
Incomplete resident medical records were identified for two residents. One resident had diagnoses including DM, interstitial pulmonary disease, HF, and CKD, but physician notes for urinary concerns and follow-up visits were missing from the facility EHR. Another resident with HF and DM had SOB and a nearly 10-pound weight gain, and an outside NP note with new orders for a chest X-ray and labs was not included in the resident's chart. Staff stated the facility relied on outside EHR access or faxed records rather than routinely incorporating those notes into the facility record.
Incomplete and Inconsistent AD and POLST Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for residents reviewed for Advance Directive (AD) and POLST documentation. Surveyors found that material differences between residents’ documented treatment preferences in their ADs and POLSTs were not identified or clarified in the medical record, and staff also inaccurately documented whether an AD had been reviewed when completing a POLST. The report states this resulted in residents’ records containing inaccurate and/or unreconciled treatment-preference information. For one resident, the AD directed that artificial nutrition and hydration be provided indefinitely unless it clearly increased suffering and was no longer in the resident’s best interest, while the POLST documented “No decision made” for medically assisted nutrition. The POLST also lacked the physician’s date next to the signature. During interview, an LN confirmed the signature but stated he/she did not believe the resident had an AD at admission and acknowledged, “I probably did that wrong.” The resident’s record did not contain a revised POLST after the AD was completed. For other residents, the ADs and POLSTs also did not match or were incomplete. One resident’s AD stated artificial nutrition and hydration should be part of comfort care and not used to artificially extend life, while the POLST again documented “No decision made” for medically assisted nutrition. Another resident’s AD indicated comfort care only and no artificial nutrition and hydration, yet the POLST selected CPR and full treatments and also documented “No decision made” for medically assisted nutrition. A fourth resident’s AD indicated a wish to receive artificial nutrition and hydration indefinitely, while the POLST documented “No decision made” for medically assisted nutrition and marked “Advance directive not available.” Staff interviews showed the LN had been checking “yes” on the POLST AD-review section without access to the AD, the RA had not been reviewing POLSTs against ADs, and the DON stated responsibility was shared among staff and that the IDT meeting should identify and correct differences.
Incomplete and Inconsistent Documentation of ADL Care and Skin Treatments
Penalty
Summary
The facility failed to maintain complete and accurate documentation in the medical record for ADL care and skin-related treatments. For one resident, shower/bath documentation from 7/01/2026 through 8/10/2026 showed multiple dates with no entries, and the task list contained bathing refusals that did not consistently match the printed shower/bath sheets. The record also lacked documentation that the resident’s physician or resident representative was notified about refusals of ADL care. Staff stated that residents who refused bathing were to be offered care multiple times, the outcome documented, and the nurse notified, but those steps were not reflected in the record. For another resident, the TAR did not document ordered wound care on several dates for a right lower extremity wound and on two dates for a left lower extremity wound. The wound care orders required cleansing, ointment, dressings, and wrapping, but the TAR showed missing documentation on multiple days in July 2026. An LPN stated that the wound care had been completed but was not documented. For a third resident, observation showed a dated dressing on the left arm and dated lidocaine patches, while the TAR reflected dressing completion and patch application/removal on different dates. Staff involved stated they were not familiar with the resident’s skin tear dressing orders or could not recall the care provided, while the DON stated that a check mark in the MAR meant the care was completed and nurses were expected to document care accurately. During observation, one resident was seen without compression stockings despite an order for daily compression stockings to both lower extremities. The DON stated that doctor’s orders were expected to be carried out and refusals charted. The report also included facility policies requiring accurate, timely documentation of assessments, observations, and services provided, and stating that documentation should reflect actual resident experiences and be completed at the time of service or by the end of the shift.
Incomplete and inaccurate resident clinical documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for one resident with hemiplegia, diabetes, and dementia. Review of the resident’s behavior monitoring showed inconsistent documentation from April through July 2026, including no wandering documented in April, exit-seeking behavior documented in May, exit-seeking and wandering documented in June, and additional exit-seeking, agitation, frustration, and threatening behaviors documented in July. The record also showed a new physician order on 4/12/26 for a Wanderguard to be placed, but there were no progress notes created that day. The clinical record contained a progress note on 4/13/26 stating the resident’s brother was informed about the Wanderguard, and another physician note on the same date stated the resident had been found wandering outside on the curb and now had a wander guard on. A later progress note repeated that statement, but the Nursing Home Administrator stated the note was inaccurate and that the resident was not found outside on the curb. The facility’s investigation found the physician note had been entered mistakenly based on word of mouth staff statements, that a staff member clarified the resident had been near the Hickory unit doorway rather than outside the facility, and that no elopement occurred. Surveyors determined the record therefore was not complete and accurately documented.
Incomplete and inaccurate resident record documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for multiple residents. Review of the facility policy stated documentation in the medical record must be objective, complete, and accurate. Surveyors identified inaccurate or incomplete documentation involving advance directives, medication administration records, monitoring records, and a physician progress note across several resident records. For one resident, the POLST showed that an advance directive was available and reviewed, but the section for the Health Care Agent was left blank even though the resident’s advance directive named a designated agent for health care decisions. The resident’s H&P also noted fluctuating capacity to understand and make decisions. For another resident, the MAR for opioid overdose monitoring contained entries of YES or Y on multiple shifts, while the order required staff to document N if the resident was monitored and none of the listed symptoms were observed, or Y if symptoms were observed. A nurse stated that Y or YES meant symptoms were present and N meant symptoms were not present, and the DON stated the documentation should reflect whether the resident was monitored and whether symptoms were present. Surveyors also found that a resident’s IV administration record did not show whether ertapenem was administered on one scheduled day during a 10-day IV antibiotic course for UTI. In another record, a physician progress note was dated after the resident had already been transferred to the acute care hospital and had not returned to the facility. The report also noted a POLST section marked as advance directive not available for a resident whose social services assessment showed the resident did not have an advance directive and had declined to formulate one, and the facility acknowledged the findings during interviews.
Falsified vital signs documented in resident record
Penalty
Summary
The facility failed to ensure one resident's medical record was accurate and free from falsified information. Resident #60 was admitted with diagnoses including multiple left rib fractures, falls, acute respiratory failure with hypoxia and hypercapnia, type 2 diabetes mellitus with diabetic peripheral angiopathy, CHF, PVD, left knee osteoarthritis, and atherosclerotic heart disease. The resident's admission MDS indicated the resident was cognitively intact. Review of the vital signs record showed Agency RN #142 documented a pulse of 66 beats per minute, blood pressure of 119/70 mmHg, and respirations of 18 breaths per minute at the same time on the evening of 07/11/26. Facility security footage reviewed with the DON showed that the RN came on shift that morning and entered the resident's room briefly on two occasions, but did not have the vital sign machine with her and there was no evidence that vital signs were taken. The DON verified that no staff present during the shift took the resident's vital signs, and the RN later confirmed by telephone that she did not take any vital signs during the entire shift despite documenting them in the record. The RN stated that if she did not have machinery, she did not like to palpate a pulse and said she always got a false pulse because she felt her pulse, but could see a pulse.
Incomplete Resident Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for 2 of 3 residents reviewed. One resident had diagnoses including diabetes, interstitial pulmonary disease, heart failure, and chronic kidney disease, and progress notes documented urinary concerns on 7/20/26, an acute visit on 7/22/26, and a video discharge visit on 7/23/26; however, review of the facility's EHR did not identify physician notes for those encounters. Another resident had diagnoses of heart failure and diabetes, moderate cognitive impairment, and recent concerns about fluid retention, including a nearly 10-pound weight gain and shortness of breath. Although a nurse practitioner note from an outside provider system documented evaluation for shortness of breath and weight gain with new orders for a chest radiograph and laboratory studies, the note was not in the resident's facility EHR. Interviews with nursing staff and the regional nurse consultant confirmed the facility did not routinely obtain records from the outside provider's EHR for inclusion in the resident's chart and relied on selected records being faxed or available in the outside system. The nurse manager stated the outside records were not considered part of the facility medical record, and another nurse stated she did not have access to the outside EHR and would be unable to review a physician note or verify an order if it was not in the resident's facility EHR. The facility's Documentation Standards Policy required records to be accurate, timely, complete, and reflective of the resident's condition, care provided, and status changes.
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