Inaccurate Clinical Documentation of Resident Presence and Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s clinical record contained accurate documentation in accordance with accepted professional standards. The resident was admitted on 11/28/23 and was later involved in a resident-to-resident altercation on 9/10/25, after which a physician ordered the resident to be sent to the ER for treatment and evaluation at 11:06 AM. Certified nursing assistant (CNA) documentation for that same date and the 7:00 AM to 3:00 PM shift recorded the resident as “not available” for all ADL tasks. However, during an interview, the CNA confirmed that the resident was in the facility at approximately 12:15 PM on 9/10/25 and that the “not available” documentation was inaccurate. In a separate interview, the Regulatory Compliance Advisor confirmed that the resident was sent to the ER at 12:15 PM and that the documentation should have reflected that the resident received care prior to leaving the facility. These findings were reviewed with the Nursing Home Administrator, Quality Manager, and DON during the exit conference, confirming that the clinical record did not accurately document the resident’s presence and care provided before transfer to the ER on the date of the incident.
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