F0842

E

Incomplete and Inconsistent Medical Record Documentation for Weights, Vitals, and Falls

Olympia, Washington Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete, accurate, readily accessible, and systematically organized medical records for multiple residents. For one resident with alcoholic cirrhosis, esophageal varices, and alcohol dependence, the quarterly MDS documented no cognitive impairment and partial to moderate dependence for ADLs, and an order summary showed daily weights were to be taken. However, the TAR for December showed daily weights missing on 5 of 31 days, and the TAR for January showed daily weights missing six times. The resident reported that staff did not understand the importance of monitoring weights and vital signs, that they personally tracked vitals, and that weights and vitals were missing when they went to outside appointments, stating that staff performed these tasks inconsistently or not at all. A nursing assistant stated staff had inconsistent assignments and did not always know which residents needed vitals or weights, and the DON stated staff should be aware of when to take weights and vitals.

For a second resident with dementia and metabolic encephalopathy, the admission MDS documented severe cognitive impairment and total dependence for ADLs, and the care plan identified fall risk with interventions such as non-skid socks, low bed position, and reminders to use the call light. The resident experienced a fall, was found on the floor with left lower extremity pain, and an x-ray later confirmed a left hip fracture. Progress notes documented the fall, pain, and x-ray results, but the record did not include documentation of the resident’s status before transport to the hospital. EMS notes indicated facility staff could not articulate details of the fall, only stating it occurred around midday, and that they were unable to obtain a mobile x-ray until the evening and did not have a copy of the x-ray. EMS documentation also noted uncertainty about whether the resident hit their head while on an anticoagulant, and described significant swelling and pain in the left leg and the resident’s verbal distress. A staff member later acknowledged they could not determine the resident’s status while waiting for hospital transfer from the record and that documentation was missing, and the DON confirmed a lack of documentation on the resident’s status after the fall and could not speak to whether the injury was immobilized due to missing documentation.

For a third resident with a history of stroke and COPD, the MDS documented no cognitive impairment and partial to moderate dependence for ADLs, and the care plan identified fall risk with interventions similar to the other resident at risk for falls. A fall report documented that this resident was found lying on the right lateral side of the bed, with no injuries noted, stable vital signs, complaints of head and left shoulder pain, and subsequent transport to the hospital. However, progress notes did not reflect the fall event. An SBAR communication form to the hospital documented the onset of increased chronic pain to the scalp and right shoulder but did not document that a fall had occurred. The DON stated that staff did not document the fall in the medical record or on the hospital communication forms. These omissions across multiple residents demonstrate incomplete and disorganized documentation of ordered monitoring, fall events, and resident status in the medical record.