F0842

E

Incomplete and Missing Clinical Documentation for Treatments, Tube Feeds, IV Antibiotics, and Weights

Kerrville, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete, accurate, readily accessible, and systematically organized clinical records for multiple residents, as required by professional standards. For one cognitively intact female resident with a right medial thigh lymphatic ulcer present on admission, the Treatment Administration Records (TARs) for January and February showed multiple blanks where daily and bedtime wound care orders were scheduled. Specifically, there were no documented wound treatments on numerous ordered dates and times, and progress notes did not reflect that wound care was performed on those dates. The facility’s wound care policy required documentation of the date wound care was given, the initials of the person performing the care, and notation of refusals, but this information was missing for several ordered treatments. Interviews with the wound care nurse, ADON, DON, and administrator confirmed that a blank on the record was interpreted as care not done or not documented, and one nurse acknowledged she believed she may have missed at least one scheduled wound care treatment during a busy period.

The same resident’s diagnosis list was also incomplete. Multiple wound-related documents, including a wound NP note, wound assessment reports, and a physician progress note, identified the right medial thigh wound as a lymphatic ulcer associated with lymphedema. However, the resident’s Medical Diagnosis tab did not list lymphatic ulcer or lymphedema as diagnoses. The DON stated that diagnoses should be added when new issues arise or persist and acknowledged that lymphedema should have been part of this resident’s diagnosis list. The administrator similarly stated that not having a diagnosis listed might impact a resident’s treatment.

For a second female resident with metabolic encephalopathy, protein-calorie malnutrition, dysphagia, and a PEG tube, the Medication Administration Records for January and February showed blanks on several days when continuous enteral feeding at a specified rate was ordered. On some dates, an exemption code of “Other / See Progress Notes” was used, but corresponding progress notes did not consistently document that tube feeding was provided or explain the exemption. On other dates, there were no entries at all for the scheduled tube feeding, and progress notes did not document that the feeding was given. The DON reported she closely monitored this resident’s tube feeding and believed no feedings were missed, but acknowledged that staff may not have charted when the feed was already running at the scheduled time and stated her expectation that staff still document the administration.

For a third male resident with a history of intracerebral hemorrhage and UTIs, the Medication Administration Records for an IV imipenem-cilastatin order scheduled four times daily showed missing documentation at specific 5:30 p.m. doses on three separate dates. One of these times was coded as “Other / See Progress Notes,” but there were no corresponding progress notes documenting the IV antibiotic administration at that time, and the other two times were left blank with no entries. The facility’s medication administration and medication error policies defined medications as to be administered as ordered and identified omissions as medication errors, but the clinical record did not show that the ordered IV doses were given or refused, nor did it provide explanatory documentation.

For a fourth cognitively intact female resident with COPD, anxiety disorder, and protein-calorie malnutrition, the record showed failures in weight documentation. The care plan included interventions to monitor and evaluate the resident’s weight, and a physician order required weekly weights. However, the weekly weight was not documented for one of three weeks in the specified period, and a separate order to obtain a weight on a specific date was entered and confirmed but not documented as completed in the record. Additionally, the resident’s weight was not documented on two dates as required by the care plan and physician order. The Order Summary Report did not reflect current active orders regarding weight monitoring, and the clinical record lacked the required weight entries on the ordered dates.