F0842

E

Incomplete and Inaccurate Clinical Documentation for Two Residents

El Paso, Texas Survey Completed on 03-12-2026

Penalty

Fine: $124,950

Summary

The deficiency involves the facility’s failure to maintain complete and accurate clinical records in accordance with professional standards for two residents. For Resident #1, who had multiple comorbidities including coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, and a recent left below-knee amputation, the attending physician evaluated her for new abdominal pain and diarrhea and ordered abdominal ultrasound (US), KUB, and multiple labs (CBC with differential, comprehensive panel, lipase, amylase). These new orders and subsequent diagnostic activities were not consistently or accurately documented. LVN C did not document on the date of the new orders that the physician had ordered labs and abdominal imaging, nor that labs were pending. RN A, the weekend supervisor, did not document when the abdominal US and KUB results were sent to the attending physician. On the following days, LVN C and LVN D did not document any follow-up on the lab orders that remained pending, and LVN H also failed to document follow-up on these same lab orders. When labs were finally drawn, LVN C did not document that the labs were drawn and that results were pending, and LVN D did not document at shift change that pending lab results had been reported to her.

Further documentation failures occurred when critical lab results and insulin orders were communicated. LVN B did not document in Resident #1’s clinical record that he received a telephone call from the lab reporting critical lab results that had been outstanding for two days. He also did not document a telephone order from the physician for a STAT dose of Lantus 10 units when the resident’s blood glucose was elevated to 517 mg/dL, and this STAT Lantus order was not entered on the Physician Order Summary. The Medication Administration Record for the month did not show documentation that the STAT Lantus dose was administered as ordered. A nurse note by LVN B described the resident crying with abdominal pain, receiving PRN hydrocodone, having blood sugars of 473 mg/dL and then 515 mg/dL, and receiving multiple STAT doses of Lispro and Lantus per physician orders, but these insulin orders and administrations were not fully or accurately reflected in the formal order summary and MAR. Additionally, the DON and Dietary Manager did not document in the resident’s electronic record concerns voiced by the resident’s family member regarding the resident’s prescribed diet.

For Resident #2, who had dementia, diabetes mellitus, hypertension, end-stage renal disease, adult failure to thrive, and malnutrition, the facility also failed to document family concerns and follow-up actions in the clinical record. The resident had a care plan addressing ADL self-care deficits, impaired cognition, nutritional problems, and a therapeutic diet, including a liberal renal diet with regular texture, health shake, HS snack, and potassium-rich foods for breakfast. The family member reported concerns about the food served for dinner on a specific date, stating the resident received a very small baked potato, small salad, and ice cream, and also raised concerns about how staff styled the resident’s hair with ponytails and bright-colored accessories, which the family felt did not treat the resident with dignity and respect. The family further reported that the resident did not eat the sack lunches sent to dialysis, that staff did not check the reusable blue bag upon return to see if the lunch was eaten, that a long-owned blanket had gone missing without being reported to administration or social work, and that care plan meetings were not consistently scheduled or that the family was not invited after staff changes. The DON acknowledged he did not keep notes and had not documented the family’s dietary concerns in the electronic record. The Dietary Manager acknowledged she had not completed a grievance/concern form, had not documented her follow-up calls to the family, and had not documented in the resident’s clinical record her follow-up on the concerns about the dinner meal. These omissions collectively demonstrate that the facility did not ensure that all services provided, changes in condition, and family concerns were documented in the residents’ medical records as required by the facility’s charting and documentation policy.