Failure to Maintain Accurate and Complete Medical Record for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with significant cognitive impairment and multiple medical diagnoses. The resident was admitted with encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions, with severely impaired cognitive skills and total bowel and bladder incontinence. On a change of condition (COC) form dated 2/13/2026, a CNA reported to an LVN that the resident had blood‑tinged urine in their diaper at 3 a.m. and again at 6:30 a.m. However, the COC also showed that the family member was notified at 12 midnight, a time that preceded the first documented episode of blood‑tinged urine. During review, the DON confirmed that the midnight entry was not an accurate time and stated that the LVN should have documented the actual time the family member was called. The facility also failed to document invasive nursing procedures performed to obtain urine specimens for ordered urinalysis and culture and sensitivity testing. Physician orders dated 2/13/2026 included urinalysis with culture and sensitivity and allowed straight catheterization if a clean‑catch specimen could not be obtained. An RN stated that on 2/13/2026 she, with assistance from an LVN, performed straight catheterization on the resident to obtain a urine sample, but there was a labeling issue with the specimen. The assisting LVN confirmed she helped with the straight catheterization on 2/13/2026 and that she later performed another straight catheterization on 2/14/2026 after learning the specimen should have been placed in a tube instead of a cup. The LVN acknowledged that neither the initial nor the repeat straight catheterization was documented in the resident’s medical record, despite recognizing that these were invasive procedures and that documentation of how the resident tolerated them was important. The DON confirmed that these procedures should have been documented and that the facility failed to record two invasive procedures in the resident’s record. Additionally, the facility did not document physician notification of the resident’s laboratory results. Laboratory reports showed that the urine specimen was received on 2/17/2026, with urinalysis results reported to the facility that evening and urine culture results reported three days later. Review of the resident’s progress notes for those dates revealed no documentation that the physician was notified of either the urinalysis or urine culture results. An RN stated she worked earlier shifts on both days and that LVNs on later shifts should have received the faxed lab results and sent them to the physician, and she acknowledged that the results may have indicated signs of a urinary infection and that nurses should have documented physician notification. The DON confirmed there was no documented evidence of physician notification for these lab results and stated that failing to document meant physician notification was not done, and that the facility’s charting and documentation policy—which requires complete, accurate, objective documentation of services, procedures, and notifications—was not followed, resulting in an incomplete and inaccurate medical record for the resident.
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