F0842

D

Inaccurate Documentation of Resident Burn Location and Date

Torrance, California Survey Completed on 02-11-2026

Penalty

Fine: $14,015

Summary

The deficiency involves inaccurate clinical documentation related to a resident who sustained a thermal burn. The resident, admitted with Parkinson’s disease and assessed as having moderately impaired cognition, experienced a burn injury from an accidental spill of hot tea. A nursing note dated 12/28/2025 documented the burn as being on the resident’s right forearm, describing erythema and superficial skin peeling consistent with a partial thickness burn. This documentation was incorrect, as the injury actually involved the resident’s right lateral leg.

A subsequent Change of Condition (COC) note dated 1/13/2026 documented a thermal burn to the resident’s right lateral leg from an accidental hot tea spill, which was the same injury but recorded with a different body location and date. During interview, the LVN who wrote the original note stated that an audit identified his error in documenting the burn location and that he was instructed to correct the documentation. He reported being unable to change the original COC note, which had been initially dated 12/28/2025, and instead created a new COC note dated 1/13/2026. The DON, after reviewing both entries, stated that this documentation made it appear as if the resident had two different burn injuries. The facility’s charting and documentation policy required care-specific details, including accurate date, time, and assessment data, which were not met in this case.