F0842

E

Failure to Maintain Accurate Clinical Records for Behavioral Events and Oxygen Therapy

Tucson, Arizona Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate, complete, and readily available clinical records that reflected residents’ actual experiences and care. For one resident with borderline personality disorder, PTSD, chronic pain, insomnia, depression, anxiety, and factitious disorder, the record did not contain documentation of significant behavioral events and roommate conflicts that occurred during room changes, despite facility policies requiring documentation of changes of condition and related nursing actions. This resident was cognitively intact, had a care plan addressing confabulation and false accusations, and had a grievance on file about room placement. A facility-reported incident later concluded that an allegation of resident-to-resident abuse was unverified and characterized the event as a verbal disagreement, but there was no corresponding documentation in the clinical record of the verbal disagreement or room-change-related distress during the 72-hour significant change-of-condition period.

The resident reported to surveyors that she was placed in two different roommate situations that she felt compromised her mental health and safety, including one roommate who required the door to remain open, which she stated exacerbated her neurological condition and pain, and another roommate who allegedly mocked her and threatened to suffocate her. She described repeated verbal altercations, a screaming match, and subsequent night terrors related to her PTSD. Staff interviews confirmed that the ADON received calls about the resident crying and hollering during room changes, that staff reported the roommate’s comments such as questioning if the resident was a child and saying she would die there anyway, and that staff intervened and moved the resident. The LPN acknowledged hearing the resident yelling, receiving CNA reports that the conflict was related to the roommate’s comments about the resident’s dolls and behavior, and contacting the ADON, but admitted he did not document the episode, despite recognizing in hindsight that it met criteria for a behavioral incident and change-of-condition documentation. Other staff, including the DSS and DON, stated they expected documentation of these events in the clinical record and that such documentation is used for assessments, grievances, and investigations.

For another resident with type 2 diabetes, chronic pain syndrome, spinal stenosis, breast cancer, and a stage 4 sacral pressure ulcer, the facility failed to ensure the clinical record accurately reflected vital sign monitoring, oxygen therapy, hospice involvement, and related physician orders. The care plan included an intervention to monitor vital signs as ordered and record them, but there was no physician order for vital sign monitoring. The MAR/TAR showed routine documentation of blood pressure, temperature, pulse, and respirations, but no oxygen saturation entries until later in the month, and the EMR lacked oxygen saturation documentation for several days. The resident was observed with an oxygen concentrator at bedside, initially turned on without the nasal cannula in place and later with the cannula in use, yet there was no corresponding physician order for oxygen therapy until a later date, no oxygen therapy care plan until that order, and no evidence of change-of-condition monitoring orders or documentation of provider notification when the resident was hypoxic according to hospice records.

Hospice documentation, obtained after a formal request, showed that the resident’s oxygen saturation had declined on room air and that oxygen was ordered and applied by hospice staff prior to the facility obtaining a physician order. The hospice notes indicated hypoxic readings and use of oxygen at 2L via nasal cannula, but these details were not present in the facility’s EMR at the time of survey, and hospice visit notes for specific dates were not available in the record or in a hospice binder. Facility staff, including an LPN, the ADON, the medical records director, and the DON, confirmed that there was no hospice binder for the resident, no oxygen order in the EMR until later, no care plan for oxygen therapy before that order, and no documented oxygen saturation monitoring for several days. The DON acknowledged that the clinical record did not show provider notification of a change of condition or oxygen saturation monitoring and stated that if the clinical record did not accurately reflect a resident’s current status or capture a change of condition, the resident could have an adverse outcome. Facility policies on documentation, change-of-condition reporting, abuse reporting, and comprehensive care planning required complete, timely, and accurate records to support care, assessments, and investigations, which were not met in these cases.