F0842

B

Inaccurate Medical Record Entry After Resident Discharge

Buena Park, California Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The facility failed to maintain an accurate medical record for one resident when documentation was entered after the resident had been discharged. The resident had been admitted to the facility and later discharged to an acute care hospital after experiencing vomiting and distress when GT feeding was resumed; 911 was called and the resident was transferred. The resident’s H&P dated 10/31/25 documented that the resident had no capacity to understand and make decisions.

Despite the resident’s discharge to the hospital on 12/5/25, a progress note dated 12/14/25 at 1724 hours showed that the SSA documented calling the resident’s family member to schedule a care plan meeting. During interviews and concurrent closed record reviews, the DON and SSA confirmed that the resident had been discharged on 12/5/25 and that the SSA nonetheless documented the care plan scheduling call in the resident’s progress notes. The SSA stated she based care plan meeting schedules on the MDS calendar and would check the current census before calling families, but verified that she had called and left a voicemail for the resident’s family and recorded this in the chart after discharge, making the medical record inaccurate.