F0842

E

Incomplete and Inaccurate Clinical Documentation for Multiple Residents

Huntington Beach, California Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with its own policies and accepted professional standards for multiple residents, including one who died in the facility and others with active and closed records. For one deceased resident, the record contained only brief progress notes indicating the time of death, confirmation by two licensed nurses, notification of family and administration, and completion of postmortem care. The record did not include documentation of the detailed observations, assessments, vital signs, interventions, or changes in condition surrounding the resident’s death, nor did it identify the names and titles of staff who performed these assessments and interventions. In interview, the LVN assigned to the resident at the time of death described specific assessment actions she took when notified the resident was unresponsive, including checking for a carotid pulse, observing for respirations, and attempting to obtain an oxygen saturation reading, and confirmed that all such observations and staff identities should have been documented but were not. The DON also verified that these elements should have been recorded to provide an accurate and complete account of the resident’s condition.

For another resident with dysphagia and a gastrostomy tube (GT) who was ordered NPO, the physician’s orders in the medical record specified that several medications (famotidine, ferrous sulfate, and acetaminophen) were to be administered by mouth. The MAR for the month showed these medications were documented as given via the oral route on multiple occasions. In interview, an LVN stated that this resident was NPO and received all medications via GT, and acknowledged that the ordered route should have been changed to reflect the actual route of administration. The DON was informed and acknowledged that the orders and documentation did not accurately reflect the care being provided.

For a third resident, the facility failed to document wound treatment and monitoring as ordered. The physician’s orders included application of antifungal cream 2% to the perineal area every shift and monitoring of a low air loss mattress every shift. Review of the TAR showed multiple PM shifts on which there were no nurse initials or codes to indicate whether the antifungal treatment or mattress monitoring had been completed or, if not, why they were not completed. An LVN reviewed the record and verified these blanks. The Administrator and DON were informed and acknowledged these missing entries.

For another discharged resident, the facility failed to complete and accurately document the IDT Care Plan Review and to record vital signs at the time of discharge as required by policy. The IDT Care Plan Review form for this resident’s baseline care plan meeting was missing multiple required elements, including whether the resident participated in care plan development, any explanation if the resident did not participate, the names of social services, activities, and attending physician, verification of admission record information, documentation of advance directive choices, additional comments, the social services plan of care, the summary of the discharge plan, and documentation that the resident or representative had been notified of their rights and agreed with the plan of care. It also lacked documentation of whether the physician or healthcare practitioner participated in and agreed with the care plan review. The SSD and DON both stated they attended the IDT meeting but could not recall details and verified the missing information on the form. Additionally, although the record contained earlier vital signs and a discharge note stating the resident was discharged with stable vital signs, there was no documented set of vital signs obtained just prior to discharge to show the resident’s medical status at that time. An RN confirmed that vital signs should have been taken at discharge, and the DON stated that the expectation was for nurses to obtain vital signs just prior to discharge.