F0842

E

Incomplete and Inaccurate Nursing Documentation for Skin Monitoring and New Admission

Hemet, California Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate and complete medical records for two residents in accordance with accepted professional standards and facility policy. For one resident with moderate cognitive impairment, poor balance, and iron deficiency anemia, a change in condition was identified when the resident’s son reported discoloration and a closed, dry skin tear on the left forearm. A care plan and physician order were initiated to monitor the discoloration on the left upper extremity every shift for changes in size, location, and appearance, and to notify the physician if changes were noted. However, subsequent documentation in multiple parts of the record did not consistently or accurately reflect this skin condition.

Review of this resident’s MAR for anticoagulant monitoring in December showed missing and incomplete entries, including multiple days with no "Y" or "N" documented and one day with "N" documented without supporting notes. The TAR for the same period showed inconsistent monitoring documentation, with some shifts documented and others missing, particularly for evening and night shifts over several days. Daily skilled charting from mid-December documented the skin as normal without describing the left forearm discoloration, and the weekly nursing summaries for the review period did not document the new skin change or bruise on the upper left arm. During interviews, an RN and the DON confirmed that daily skilled monitoring, weekly summaries, and other documentation should have reflected the resident’s skin condition and any changes, and acknowledged that notes were missing and that the licensed nurses’ documentation did not consistently or accurately reflect the resident’s skin condition.

For a second resident admitted with multiple left rib fractures and other injuries, the facility failed to complete progress notes in accordance with its own protocols. The resident was admitted from an acute hospital with pain to the left ribs and abdomen, on bed rest with oxygen via nasal cannula, and had documented skin findings including tenderness over the left chest wall, a partial nail avulsion to a finger, abrasions to the ankle and elbow, and a scab to the knee. An admission progress note was completed on the evening shift, and later notes documented the resident resting comfortably and then developing shortness of breath and respiratory distress during therapy, leading to transfer to the hospital. However, there was no documented evidence of the resident’s status or condition between late evening on the day of admission and the following morning. In interviews, nursing staff and the DON stated that facility protocol required progress notes each shift for all residents, and specifically for the first 72 hours after admission, and acknowledged that the night shift progress note for this resident was missing. The facility’s charting and documentation policy required that notable changes and assessment data be documented in the medical record, but this was not done for this resident during the night shift.

These findings show that for both residents, the facility did not ensure that nursing summaries, skin evaluations, monitoring records, and progress notes were complete and accurate, as required by physician orders, facility protocols, and the facility’s charting and documentation policy. The DON and nursing staff confirmed that documentation should have reflected residents’ conditions, changes in condition, and ongoing assessments, but in these cases, the records contained omissions and inconsistencies.