F0842

D

Failure to Maintain Accurate EBP Orders in Clinical Record

Edinburg, Texas Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident who required Enhanced Barrier Precautions (EBP). The resident was an elderly female with Alzheimer’s disease, chronic kidney disease, and heart failure, with a severely impaired cognition reflected by a BIMS score of 4 on a quarterly MDS. Her care plan, updated on 01/18/26, identified a need for EBP due to a history of ESBL in the urine and MRSA in a sacral wound, and included interventions such as placing her on EBP, posting signage on the door, and using gown and gloves for high-contact care activities, with additional use of mask and eye protection as indicated. The MDS did not address any care issues that would require EBP.

During observations and interviews on 02/04/26, the MDS-RN, Infection Preventionist (IP), and DON each confirmed that the resident had a history of ESBL and MRSA and should remain on EBP, and that signage and supplies were in place. However, review of the electronic medical record by the MDS-RN and IP revealed there was no active physician order for EBP; the prior EBP order had been discontinued on 01/23/26, and the IP did not know why it had been discontinued and stated it may have been in error. The IP acknowledged it was his responsibility to ensure all residents on EBP had an order and that he had missed this during his weekly reviews. The facility’s “Documentation in Medical Record” policy required that each resident’s medical record contain an accurate representation of the resident’s experiences and complete, accurate, and timely documentation of assessments, observations, and services, which was not met in this case because the resident’s ongoing need for EBP was not supported by an active order in the clinical record.