Failure to Document Behavioral Interventions After Resident Altercation
Summary
The deficiency involves the facility’s failure to document behavioral interventions as indicated on the care plan for a resident following an altercation with another resident. Resident 1 was admitted with diagnoses including anemia and schizoaffective disorder and had a documented episode of increased aggression on 2/28/2026, during which he was unable to be redirected and was considered a danger to others. On that date, Resident 1 entered Resident 2’s room, and RN 1 responded after hearing Resident 1 screaming in the hallway. RN 1 found Resident 2 holding a foldable chair, and Resident 1 reported that Resident 2 had hit him on the head with the chair. Resident 2 had been admitted with chronic kidney disease and hypertensive urgency. Resident 1’s care plan, dated 2/28/2026, included interventions for staff to provide early redirection and de-escalation techniques to reduce episodes of verbal aggression. Record review of Resident 1’s progress notes for 2/28/2026 showed that the incident occurred at 11:20 a.m. and that Resident 1 was picked up for transfer at 4:45 p.m., but the notes did not document any early interventions, redirection, or de-escalation measures taken during the period when Resident 1 was intermittently yelling while awaiting transfer. RN 1 acknowledged that the progress notes did not indicate early interventions, redirection, or de-escalation that were done during Resident 1’s episodes of screaming. The ADON confirmed that Resident 1 was alert, oriented, ambulatory, and had episodes of screaming on 2/28/2026, and stated that the progress notes did not document interventions, including non-pharmacological ones. The DON stated that care plan interventions should have been documented if they were completed and that following care plan interventions was important to prevent further behavioral escalation and to keep residents and staff safe. The facility’s policy on Behavioral Assessment, Intervention, and Monitoring required that any improvements or worsening in behavior, mood, and function, as well as new or emergent symptoms, be documented and reported.
Plan Of Correction
How corrective action (s) will be accomplished for those residents found to have been affected by the deficient practice; On March 5, 2026 the Director of Nursing (DON) and Assistant Director of Nursing (ADON) immediately reviewed and updated their care plan to ensure all behavior interventions are current. On March 5, 2026 the DON and Administrator counsel the charge nurse on the specific required documentation following an altercation. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; The facility of Medical Records and DON conducted an audit of care plans for residents with known behavioral episodes were documented, and any discrepancies found during this audit were corrected immediately. On March 6 and March 20, 2026, the Director of Nursing (DON) conducted in-service training for licensed nurses regarding behavioral de-escalation. The sessions specifically emphasized the requirement to document care plan interventions implemented when a resident exhibits behavioral symptoms. What measures will be put into place or what systemic changes will the facility make to ensure that deficient practice does not recur;The Medical Records Director (or designee) will conduct daily audits of the Electronic Medication Administration Record (EMAR) behavior monitoring. These audits will ensure that for every resident with a documented behavior, corresponding care plan interventions are implemented and charted. All findings will be reported directly to the Director of Nursing (DON) and Administrator for review.On March 6 and March 20, 2026, the Director of Nursing (DON) conducted in-service training for licensed nurses regarding behavioral de-escalation. The sessions specifically emphasized the requirement to document care plan interventions implemented when a resident exhibits behavioral symptoms. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action is evaluated for its effectiveness. The POC is integrated into the quality assurance system; andThe Medical Records will perform weekly audits of behavioral monitoring and progress notes for four weeks, then monthly for the three months. The results of these audits will be reported to the Quality Assurance and Performance Improvement (QAPI) committee for further review and to determine if additional training or systemic adjustments are necessary.Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency.All corrective actions will be monitored daily, weekly compliance audits will be conducted by the Medical Record for four weeks then monthly for three months there after that with all findings reported to the committee members during the facility's QAPI meetings.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete and inaccurate medication orders were found for two residents after record review and staff interviews. One resident’s Toujeo insulin glargine order listed conflicting clinical indications, with staff stating the order had been mistyped, and another resident’s hydroxyzine HCl PRN anxiety order omitted the dose even though the resident had previously been receiving 25 mg tablets.
Missing discharge and transfer orders in resident records: The DON confirmed that discharge or transfer orders were not obtained or documented for multiple residents. One resident was discharged back to an ALF in stable condition after insulin instructions were reviewed, another had a note stating the MD ordered hospital transfer but the order was not completed in the record, and a third had respiratory distress and altered mental status with an MD order to send to the ER, but no transfer order was found. The facility policy required a physician order for emergency transfer or discharge.
Incomplete death documentation: A resident’s record lacked progress notes and an incident report describing what occurred when the resident passed away in the facility. Although the chart included the POLST, death record, MDS, and an encounter note stating CPR was started and 911 was called, facility leaders verified there were no documents covering the morning of the death.
A resident with depression, chronic pain, and COPD had an order for PRN oxycodone 10 mg. The medication was signed out on the narcotic accountability record multiple times, but there was no matching MAR documentation. The LVNs stated they administered the doses but failed to chart them on the MAR due to human error, and the DON confirmed the documentation was incomplete.
Incomplete Documentation of Care Conference Participation: The facility failed to accurately document whether two residents or their responsible parties were informed of, attended, or declined quarterly care plan conferences. One resident had COPD, seizures, dysphagia, hypotension, and cognitive impairment, while the other had AFib, HF, HTN, hypothyroidism, hyperlipidemia, dementia, and depression. Care conference forms showed staff attendance, but the sections for resident or RP participation were left blank, and an LVN acknowledged she did not document the invitations or attendance status in the EMR.
Incomplete Documentation of Chronic Scalp Wound: A resident with a chronic scalp lesion/wound had inconsistent and incomplete skin/wound documentation in the EMR. Weekly skin assessments sometimes omitted the lesion entirely, and when it was documented, key details such as size, shape, color, and drainage were missing. The record also lacked documentation of a comprehensive assessment after maggots were found and removed from the wound, and staff acknowledged the chart did not provide a complete picture of the wound status or care provided.
Incomplete and inaccurate medication orders in resident records
Penalty
Summary
The facility failed to ensure a physician order was clarified for its clinical indication and medication dosage, resulting in inaccurate documentation in the resident medical record. The deficiency was identified through record review and staff interviews and involved 2 of 2 residents reviewed. The facility’s documentation policy stated that the resident medical record should be accurate, objective, and clinically relevant. One resident was admitted and readmitted with diagnoses including morbid obesity with alveolar hypoventilation and diabetes. A physician order listed Toujeo SoloStar insulin glargine 300 units/ml as 120 units subcutaneously one time a day related to morbid obesity with alveolar hypoventilation, and also listed Toujeo SoloStar insulin glargine 300 units/ml as 120 units subcutaneously at bedtime related to type 2 diabetes. During interview, the CRN stated the evening dose was for diabetes and the morning dose was for obesity, then later stated the insulin glargine order should have been for diabetes and not obesity and had been mistyped by the nurse. Another resident was admitted and readmitted with diagnoses including quadriplegia, depression, and anxiety disorder. That resident’s MAR showed an order for hydroxyzine HCl every 8 hours as needed for anxiety, but the order did not include a dose. The CNO confirmed the dose was missing and stated the resident had previously been receiving hydroxyzine 25 mg tablets and the person entering the order did not catch the 25 mg.
Missing discharge and transfer orders in resident records
Penalty
Summary
The facility failed to ensure that discharge or transfer orders were present in the medical records for 3 of 4 residents reviewed for discharge. Resident #120 was admitted with diagnoses including type I diabetes mellitus with hyperglycemia, gastroparesis, schizophrenia, depression, hypothyroidism, dysphagia, anemia, hypertension, cognitive communication deficit, and long-term insulin use. A health status note documented that the resident was discharged back to an ALF in stable condition, with discharge instructions provided and explained, insulin administration reviewed, and transportation arranged by facility staff; however, the DON stated that no discharge orders were obtained. Resident #3 was admitted with diagnoses including hyperkalemia, gastrostomy care, hypertensive chronic kidney disease, acute kidney failure, type 2 diabetes mellitus with diabetic chronic kidney disease, COPD, atherosclerotic heart disease, anemia in chronic kidney disease, and muscle weakness. A progress note stated that the MD reviewed labs and ordered the resident sent to the hospital, but the record did not contain the completed order, and the DON stated the paperwork had been completed for discharge but no physician order was written. Resident #118 was admitted with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, hypertensive heart disease with heart failure, dysphagia following CVA, and muscle weakness; a progress note documented respiratory distress and altered mental status, with the MD notified and ordered the resident sent to the ER, but the physician orders did not show an order to transfer the resident from the facility to the hospital. The facility policy required a physician order for emergency transfer or discharge and for anticipated discharge to the community.
Incomplete Death Documentation
Penalty
Summary
The facility failed to maintain a complete, accurate, and readily accessible medical record for one resident, R29, related to the resident’s death in the facility. R29’s hospital discharge summary showed discharge to the nursing home in stable condition, and the POLST indicated attempt CPR. The death record listed the date of death, and the MDS assessment indicated death in facility, but the progress notes did not document the resident’s death or what occurred. The encounter note stated that a call was received that R29 had passed away that morning, CPR was started, and 911 was called. When the state agency requested the incident report and medical record items related to the day of death, the facility did not have an incident report or progress note documenting what occurred that morning. During interview, the administrator and VPS-A and VPS-B verified the facility did not have documents of what occurred the morning of R29’s death.
Incomplete Documentation of Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that Resident #1’s medical record was accurately documented and complete when controlled substance administration was signed out on the narcotic accountability record but not documented on the MAR. Resident #1 was admitted with diagnoses including depression, chronic pain, and COPD, and had a BIM'S score of 15 indicating intact cognition. The care plan included administering medications as ordered, and the June 2026 physician orders included Oxycodone 10 mg every 6 hours as needed for pain. Record review showed that Oxycodone 10 mg was signed out on the controlled substance administration log on 6/15/2026 at 4:30 AM, 10:30 AM, and 4:30 PM, but there was no corresponding documentation on the MAR for those administrations. During interview, the resident stated he was not 100% sure whether he received the medication at those times. The LVN staff assigned to those shifts stated they administered the Oxycodone as recorded on the controlled substance log but did not document it on the MAR due to human error, and the DON confirmed that nursing staff had not been recording controlled substances on the MAR after signing them out on the narcotic count record.
Incomplete Documentation of Care Conference Participation
Penalty
Summary
The facility failed to maintain medical records that were complete and accurately documented for 2 residents reviewed for documentation. For both residents, the electronic medical record did not show whether the resident or the responsible party had been informed of, attended, declined, or otherwise participated in the quarterly care conference meetings. The deficiency was identified through record review and interviews, and the Care Conference & DC Case Management Evaluation forms did not reflect resident or responsible party attendance status. Resident #9 was a female with diagnoses including COPD, seizures, dysphagia, hypotension, and major depressive disorder. Her MDS showed unclear speech, moderate cognitive impairment with a BIMS score of 8, wheelchair use, and varying levels of assistance with eating, dressing, transfers, bed mobility, and toileting. Her care plan included impaired cognitive function and psychosocial well-being focus areas with interventions to provide opportunities for the resident and family to participate in care. The care conference evaluations reviewed for this resident showed that conferences were held in person with staff attendance, but the section for resident or responsible party participation was not completed, and no evaluation was available for two of the expected quarterly conferences. Resident #24 was a female with diagnoses including atrial fibrillation, heart failure, hypertension, hypothyroidism, hyperlipidemia, dementia, and major depressive disorder. Her MDS showed intact cognition with a BIMS score of 15 and no vision, hearing, or communication deficits, along with dependence in several activities of daily living. Her care plan included falls, altered cardiovascular status, discharge planning, and activity involvement, with interventions involving the resident or family. The care conference evaluations reviewed for this resident showed in-person conferences attended by facility staff, but the form did not document whether the resident or responsible party attended, refused, or were invited and absent. During interview, the resident stated she was aware of care plan meetings but could not recall being invited every 90 days and said she chose not to attend because little changed. An LVN acknowledged she invited the resident and sent invitations to the responsible party but did not document that information in the EMR, and the DON stated the form was expected to be completed in its entirety.
Incomplete Documentation of Chronic Scalp Wound
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a chronic scalp lesion/wound. Weekly skin assessments from 6/2/25-6/29/25 and 11/2/25-11/16/25 contained no documentation of the resident’s scalp lesion/wound, while assessments from 7/6/25-9/28/25 and 12/14/25-6/14/26 documented the presence of the lesion/wound but did not include complete details such as size, shape, color, or drainage characteristics. The resident’s electronic medical record also showed no documentation that a comprehensive assessment of the chronic scalp lesion/wound was completed after maggots were identified and removed from the lesion/wound on 6/12/26. During interviews, staff stated that weekly skin assessments were completed, that nursing staff were expected to document skin and wound assessments, and that documentation should include at minimum a description of the skin concern, wound description or measurements, shape, color, drainage, and odor. Staff acknowledged the record did not contain all information needed to provide a complete picture of the resident’s wound status and related care provided.
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