F0842

D

Inaccurate and Delayed Change-of-Condition Documentation

Sylmar, California Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an accurate, complete, and timely medical record for one resident who experienced a change of condition related to an incident of physical aggression by another resident. The resident had been admitted with diagnoses including type 2 diabetes mellitus, Alzheimer’s disease, and essential hypertension, and had severely impaired cognitive skills for daily decision-making per the most recent MDS. A CNA reported that another resident attempted to hit this resident on the evening of 3/9/2026, and an LVN responded to the incident. The LVN later created a Change of Condition (COC) Evaluation but documented the COC as occurring on 3/10/2026 during the night shift instead of on 3/9/2026 during the 3 p.m. to 11 p.m. shift when the incident actually occurred.

The COC Evaluation also contained inaccurate information regarding the timing of notifications to the resident’s attending physician and family member. The form indicated that the physician was notified at 9:20 p.m. and the family member at 9:15 p.m. on 3/10/2026, while the LVN stated that both were notified after midnight on 3/10/2026 but could not recall the exact times. The LVN acknowledged that the COC Evaluation was inaccurate. The Assistant DON confirmed that the resident’s change in condition occurred on 3/9/2026, that the COC Evaluation was not completed and signed until 3/11/2026, and that facility policy required documentation of the correct date and time of the incident and notifications, with nursing documentation to be completed by the end of the assigned shift. These findings showed that the facility did not follow its own policies on change of condition notification and nursing documentation, resulting in inaccurate and untimely entries in the resident’s medical record.