F0842

D

Incomplete and Inaccurate Clinical Record for a Resident

Bedford, Virginia Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

Facility staff failed to maintain a complete and accurate clinical record for one resident, whose diagnoses included severe COPD, anemia, non-infectious systemic inflammatory response syndrome, hypomagnesemia, chronic pain, lung nodule, acute and chronic respiratory failure, osteoporosis, emphysema, history of thyrotoxicosis, non-ischemic myocardial injury, anxiety, and hypothyroidism. The resident was assessed as cognitively intact on the MDS. The nurse practitioner (NP) reported assessing the resident several times during the stay, but review of the clinical record initially showed only one NP progress note dated 7/3/25. During interviews, the DON later produced two additional NP progress notes dated 6/20/25 and 6/30/25 that had not been scanned or uploaded into the resident’s electronic clinical record. The administrator explained that the facility had started with new providers and transitioned to a new documentation system in June 2025, and staff had not realized that these NP progress notes were missing from the record.

The resident’s discharge summary documenting an emergent transfer to the emergency department was also inaccurate. The discharge summary was recorded with a date/time of 7/8/25 at 1:43 p.m., while the resident’s change in condition and transfer from the facility were documented as occurring at 10:45 p.m. that same day. The regional nurse consultant stated that nursing had previously documented a note with the incorrect time and then made a note regarding the correction, and that the NP’s discharge summary note reflected the incorrect time based on the earlier nursing note. The regional nurse consultant acknowledged that the discharge summary date/time should have been corrected or an addendum made to indicate the error, but this was not done, resulting in an inaccurate discharge summary in the resident’s clinical record.