Failure to Document RN Assessment and Vital Signs During Acute Respiratory Event
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and professionally acceptable medical records for a resident who experienced an acute change in respiratory and mental status. The resident had diagnoses including respiratory failure (unspecified hypoxia/hypercapnia), obstructive sleep apnea, and hypertension, and was care planned for risk of compromised respiratory status with interventions such as monitoring respiratory status, vital signs, and providing oxygen per physician order. Facility policies on Change in Resident Condition and Resident Hospital Transfer required the RN to complete and document an assessment, use an SBAR tool, and write a nursing progress note including all steps taken, the time of transfer, transport details, and report to the emergency department. On the night in question, an LPN documented that around 1:00 AM the resident was resting comfortably and remained stable and responsive through the night until approximately 5:00 AM, when the resident was found with labored respirations and minimally responsive to verbal stimuli. The LPN documented that the resident’s oxygen saturation was 40% on 4L nasal cannula, that the RN supervisor was immediately notified and came to the bedside, changed the nasal cannula to an oxygen mask, and that oxygen saturation levels were rechecked with three separate oximeters, yielding readings of 42%, 43%, and 26% with increased labored breathing. The LPN further documented that the RN supervisor was again updated with a recommendation to send the resident to the emergency department, oxygen therapy was escalated to 10L via non-rebreather mask, and that upon EMS arrival the resident became unresponsive and was transported to the hospital. Despite these events, there was no documentation in the medical record of the resident’s vital signs (heart rate, blood pressure, respiratory rate, and temperature) on that date, no documented assessment by the RN supervisor when the resident had respiratory and mental status changes, and no documented evidence of the resident’s response to the oxygen treatment provided. The nursing progress note entry for the RN supervisor at 5:57 AM was blank, and another RN later documented only that they received report from the LPN, that the resident’s oxygen saturation was in the low 40s, that the resident was unresponsive and vital signs were unable to be taken, that the RN supervisor had assessed the resident per the LPN, and that the resident was sent to the hospital and the NP was notified. In interviews, the LPN stated they had taken and written vital signs on a “cheat sheet,” and the RN supervisor stated they forgot to write a note; the DON stated they would expect RNs to write assessment notes and that the RN supervisor attempted but did not save a note in the computer system. These omissions resulted in an incomplete and non-compliant medical record for this resident’s acute change in condition and transfer.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a Stage 4 pressure ulcer and a physician’s order for Tramadol 50 mg to be given on the day shift 30 minutes before wound care had multiple missing and unexplained entries on the MAR, even though the Treatment Record showed that wound care was performed daily. On several days, there were no nurse signatures for the ordered Tramadol, and on other days the MAR was marked as “out of parameters” without any supporting progress notes. The wound care nurse reported relying on the MAR to confirm that pain medication was given before she performed wound care, and the DON stated that nurses are expected to follow physician orders and document refusals, but the record did not contain adequate documentation to demonstrate proper administration or explanation of the ordered pain medication.
Incomplete and inaccurate resident clinical records: The facility’s EMR did not accurately reflect one resident’s active psych diagnoses, with schizophrenia/bipolar history and schizoaffective disorder not carried through the MDS, care plan, diagnosis tab, or PL 1 screening. For another resident, the chart lacked a valid resident-signed MPOA and physician certification of incompetence, the admission agreement was signed by family and BOM only, and staff did not document the resident’s behaviors and statements despite noting she could express her needs and wanted to go home.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
A resident with intact cognition and diagnoses including CHF, COPD, respiratory failure with hypoxia, O2 dependence, sleep apnea, and A-fib had inconsistent documentation about the ability to self-administer nebulizer treatments. The MAR stated the resident could self-administer meds and nebulizers after set-up, but a self-administration assessment found the resident was not safe to self-administer inhalants without supervision. Surveyors also observed a handheld nebulizer still connected with medication remaining in the cup, while the MAR showed the treatment as completed and signed off by an RN.
The facility failed to accurately document PRN opioid pain medication administration on the MAR for four residents, despite corresponding removals recorded on controlled substance declining count sheets. On multiple occasions, an RN removed Oxycodone or Hydrocodone/Acetaminophen for pain from the controlled drug supply but did not chart the administrations on the MAR. In an interview, the RN reported relying on her own system, administering medications without checking the order and then failing to return to sign the MAR due to being busy and forgetting. The prior DON and current DON both stated they expect nursing staff to document pain medications on the MAR, and the NP reported she depends on MAR entries to evaluate residents’ responses to PRN pain treatment.
Inaccurate resident documentation was found for one resident receiving hospice care and one resident receiving nutritional support. A resident’s chart contained hospice records that belonged to another resident, and another resident’s dietary record showed a peanut butter sandwich as eaten even though unopened sandwiches were observed in the room. The DON and Administrator provided information about hospice uploads and staff documentation responsibilities.
Incomplete Documentation of Ordered Pain Medication Prior to Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of complete and accurately documented medical records related to pain medication administration prior to wound care for one resident with a pressure ulcer. The resident was admitted with diagnoses including peripheral vascular disease and had a care plan for a Stage 4 pressure ulcer that included administering medications and treatments as ordered. A significant change MDS indicated the resident had no cognitive impairment, required setup/cleanup assistance for eating and oral hygiene, had a Stage 4 pressure ulcer, received a scheduled pain medication regimen, and experienced moderate, occasional pain. A physician’s order dated 04/23/2026 directed that Tramadol 50 mg be given orally on the day shift for pain, 30 minutes before wound care. Review of the May 2026 Medication Administration Record (MAR) showed missing nurse signatures for the ordered Tramadol on multiple dates (05/02, 05/03, 05/09, and 05/10), despite the Treatment Record reflecting that wound care was performed daily on the day shift. On additional dates (05/04–05/06 and 05/11), the MAR entries for Tramadol were signed with code “4” indicating “out of parameters” by a registered nurse, but there were no associated progress notes explaining these entries. The wound care nurse reported that the resident had an order for Tramadol prior to wound care, that she performs wound care Monday through Friday, and that the floor nurse performs it on weekends, and she stated she checks the MAR to ensure the medication was given. The DON stated that nurses are to follow physician orders and document if a resident refuses medication. The facility’s pressure ulcer/skin breakdown protocol required pain assessment and documentation, but the medical record lacked adequate documentation to show that the ordered pain medication was administered or appropriately addressed on the identified dates.
Plan Of Correction
The facility continues to ensure that resident's medical records are complete and accurately documented. IMMEDIATE CORRECTIVE ACTION Resident #62 was assessed by Director of Nursing upon notification of surveyor and resident #62 did not have any adverse outcome related to the alleged deficient practice on 5/13/26. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. Director of Nursing and/or designee conducted a comprehensive chart audit to ensure that residents with pain medications were accurately documented on EMAR on 5/15/26. No residents were adversely affected by the alleged deficient practice. SYSTEMATIC CHANGES The Director of Nursing and/or designee initiated ongoing in-service education with clinical staff on standards of accurate medication administration documentation with emphasis on accurate documentation of Pain Medication Refusal. MONITORING Nursing Supervisor and/or designee will conduct random observation and/or audits to ensure accurate documentation of pain medication administration and refusal, 5 days a week for 1 month, then weekly for 3 months. The Director of Nursing and/or designee will report findings of observation/audits to the quality assurance committee monthly for 4 months to ensure continued substantial compliance is achieved and maintained.
Incomplete and inaccurate resident clinical records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the record contained diagnoses of major depressive disorder and schizoaffective disorder, while the admission MDS reflected depression and a history of schizophrenia and bipolar disorder that were not documented as active diagnoses. The care plan did not include bipolar disorder or schizoaffective disorder, the EMR diagnosis tab did not show bipolar disorder, the PL 1 Screening was coded No for Mental Illness despite documentation that the resident had a mental illness, and the EMR did not show submission of Form 1012. A psychiatry evaluation later documented a history of schizophrenia and bipolar disorder, described as schizoaffective disorder, depressive type, per hospital records and collateral review. For the second resident, the EMR did not contain a valid MPOA signed by the resident, and the admission agreement was signed only by the family member and the business office manager. The MPOA document in the record showed the signature acknowledged before a notary was that of the family member, not the resident. The EMR also did not contain physician certification that the resident lacked competence to make health care decisions, and it did not contain documentation signed by the resident authorizing the family member as legal guardian or agent under a medical power of attorney. Staff interviews confirmed that the resident could express needs and wants, and multiple staff members stated the MPOA was not valid because it was not signed by the resident. The record also did not include progress notes documenting the resident’s behaviors and statements while at the facility. An administrator note documented a discharge dispute involving the resident, the family member, and another family member, including the resident insisting on going home and law enforcement being called. Interviews with the Activities Director, LVN, ADON, MDS Coordinator, BOM, and Administrator reflected that the resident participated in activities, verbalized needs and wants, and discussed wanting to return home, but staff did not recall whether these statements were documented in the EMR. The facility policy stated that documentation must be complete, accurate, timely, and properly signed, and that active diagnoses and required forms should be placed in the clinical record.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Inconsistent documentation of self-administration status for nebulizer treatments
Penalty
Summary
The facility failed to ensure documentation of one sampled resident’s ability to self-administer medication was consistent and accurate throughout the medical record. The resident’s quarterly MDS, accepted on 4/6/26, identified intact cognition and multiple diagnoses including heart failure, COPD, respiratory failure with hypoxia, dependence on supplemental oxygen, sleep apnea, and atrial fibrillation. The resident required moderate assistance from one staff member for transfers, dressing, and hygiene. On 5/4/26 at 5:30 p.m., surveyors observed a handheld nebulizer in the resident’s room still connected to the nebulizer machine, with approximately half of the medication remaining in the cup, while the resident was not present. The May 2026 MAR documented that the resident received an ipratropium/albuterol nebulizer treatment at 2:00 p.m. and that RN-B signed off the treatment as completed. The MAR also stated the resident was able to self-administer oral medications and nebulizers after set-up. However, the resident’s 4/13/26 self-administration assessment completed by RN Consultant-B stated the resident was not capable of self-administering inhalants or using inhalers without supervision and was not safe to self-administer at that time. During interview, RN Consultant-B acknowledged the assessment was accurate and agreed he did not update the MAR to show the resident was no longer safe to self-administer nebulizer treatments. The interim DON stated it was her expectation that the MAR be updated immediately following the change with re-assessment.
Failure to Accurately Document PRN Controlled Substances on MAR
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the administration of controlled substances on the Medication Administration Record (MAR) for four residents, despite corresponding entries on the controlled substance declining count sheets. For one resident with an order for PRN Oxycodone 5 mg every 8 hours, Nurse #1 repeatedly documented removal of tablets on the declining count sheet on multiple dates and times, but did not document administration on the MAR for those same dates and times. A second resident with an order for PRN Hydrocodone/Acetaminophen 5 mg/325 mg every 6 hours had doses removed per the declining count sheet on two occasions, yet Nurse #1 did not record those administrations on the MAR. A third resident with PRN Oxycodone 5 mg orders (first every 4 hours for up to 7 days, then every 6 hours) had doses removed on two separate days at 8:00 AM and 12:00 PM, but again, Nurse #1 failed to document these administrations on the MAR. A fourth resident with an order for PRN Oxycodone 5 mg every 6 hours for 3 days had a dose removed per the declining count sheet, but there was no corresponding documentation on the MAR for that date. In a phone interview, Nurse #1 stated that her “system was not good,” that she knew which medications residents received and would administer them without looking at the order, and that she did not sign the MAR because she was too busy and forgot to return to complete the documentation. The previous DON stated she expected nursing staff to sign off on the MAR whenever administering pain medications and emphasized the importance of MAR documentation to determine if pain was being managed. The Nurse Practitioner reported that she relies on the MAR to assess residents’ responses to PRN pain medications, and the current DON stated she expected accurate documentation of pain medication administration on the MAR and identified that the nurse did not follow the medication administration process, which includes documentation.
Inaccurate Resident Documentation and Mixed Hospice Records
Penalty
Summary
The facility failed to accurately document clinical records for a resident receiving hospice care and for a resident receiving nutritional supplementation. For one resident with Alzheimer’s disease and a significant change MDS dated 3/13/26 indicating hospice care, the clinical record contained scanned and uploaded hospice documentation dated 4/7/26 that belonged to a different resident in the facility who was also under hospice care. The DON stated on 4/29/26 that hospice documentation was generally uploaded to the resident’s clinical record every three months, with updates to the plan of care, and when the resident passed. For another resident with heart failure, an IDT note dated 2/17/26 documented an 11.3% weight loss in 30 days and a new recommendation for a peanut butter and jelly sandwich and chips at 10:00 A.M., and physician orders reflected that snack. The dietary administration history showed the snack as provided and eaten on 4/25/26, 4/26/26, and 4/28/26. However, on 4/28/26 at 1:06 P.M., two unopened peanut butter sandwiches were observed on the bedside table and one on the dresser, with dates of 4/25/26, 4/26/26, and 4/28/26 and all marked for 10:00 A.M. The Administrator later provided a nursing job description stating that direct care staff were responsible for complete and accurate resident documentation.
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