F0842

E

Inaccurate Q15 Safety Observation Documentation by CNA

Paramount, California Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves inaccurate and incomplete maintenance of 24-hour observation checklists for residents on every-15-minute safety monitoring. On one date, a CNA documented the 10:00 a.m. and 10:15 a.m. observations for three residents in advance of the scheduled times, after conducting rounds at approximately 9:45 a.m. The CNA acknowledged that documentation was entered before directly observing the residents at the required times. For another resident, the same CNA initially left the 9:45 a.m. and 10:00 a.m. observation entries blank because the resident was not observed at those times.

On the following day, review of that resident’s checklist showed that the CNA later completed the previously blank 9:45 a.m. and 10:00 a.m. entries after seeing the resident at approximately 10:14 a.m. in the hallway, despite not having observed the resident at the scheduled times. The CNA stated she had attempted but was unable to locate the resident earlier and did not notify other staff, and that she filled in the missed times because she believed the form could not be left blank. The DSD and an RN stated that staff must directly observe residents before documenting, that pre-charting or documenting without direct observation is not acceptable and may be considered false charting, and that documentation must be accurate, timely, and reflect actual observations in accordance with facility policies on levels of observation and general documentation guidelines.