A resident’s electronic chart contained two DNR advance directive forms that did not match the resident’s DOB and were not consistent with the resident’s full code status. Staff confirmed the resident was full code, the DNR form should not have been in the chart, and the DON and medical record staff identified that the documents belonged to the wrong resident.
A resident with severe cognitive impairment, dementia, and right-sided hemiplegia had a shower incident in which staff documented a head injury, but the record did not include a fall incident or a complete head-to-toe assessment. The CNA later stated the resident tipped forward and his knees contacted the floor, while the RN said he did not perform a full body assessment and later learned the resident had a hip fracture. Hospital records showed a mechanical fall with head strike, facial laceration, and acute hip fracture, but the facility charting remained incomplete and inconsistent.
Inaccurate Smoking Care Plan Documentation: A resident with osteoarthritis, anxiety, PTSD, depression, insomnia, weakness, and a history of falls had smoking assessments documenting no impairments and ability to smoke independently, but the care plan also included interventions for staff supervision while smoking and storage of smoking materials. Staff interviews confirmed they relied on care plans and smoking assessments, and the DON acknowledged the conflicting documentation in the resident’s record.
An LPN signed out multiple doses of opioid medications for five residents on controlled substance records without corresponding entries on the MAR, including PRN oxycodone and hydromorphone orders and one discontinued oxycodone order. One resident reported not receiving narcotic medication despite a signed-out dose, and another had a discontinued narcotic documented as administered. A scheduled oxycodone ER dose was documented as wasted without a second nurse co-signature. Staff interviews confirmed that narcotics were sometimes not documented on the MAR and that required dual signatures for wasting were not consistently obtained, resulting in unresolved discrepancies between narcotic logs and medication records.
The facility failed to maintain and retain complete, accessible medical records and related documentation for numerous residents, particularly for periods before a change in ownership. Surveyors found that care plans, nursing progress notes, incident reports, five‑day investigations, grievance logs, and other records were missing or unavailable for residents involved in altercations, falls, and alleged financial misappropriation, even though federal assessment data confirmed those residents had been admitted and assessed at the facility. Staff acknowledged that records for residents admitted and discharged before the ownership change, and some records for current residents admitted earlier, were not available, and that incident and investigative records from those periods were also missing, contrary to facility policies requiring long‑term record retention and complete documentation of care and events.
The facility failed to maintain required medical records for a resident admitted in 2022 who had moderate cognitive impairment and multiple chronic conditions, including ESRD, diabetes, seizure disorder, and mental health diagnoses. When surveyors requested the resident’s chart, including the facesheet, diagnoses, physician orders, MAR/TAR, progress notes, care plan, census information, and self-reports, facility staff reported they could not provide any records from before a change in ownership because they had no access to the prior EMR system after the previous owner stopped paying for it. The Medical Records Director and DON acknowledged that records are required to be retained for 10 years, and facility policies on medical record content and record retention also required long-term maintenance of resident records and investigations, which was not achieved due to the lack of access to historical records.
A resident with dementia and severe cognitive impairment was care planned for elopement risk and wandering with multiple interventions, yet the MDS documented no wandering behavior and the wandering/elopement risk evaluation was inconsistently documented, with an entry struck out and the assessment not signed and locked until after the resident was later found outside the facility at night and sent to the hospital. Staff interviews showed differing views of the resident’s wandering risk, with an LPN reporting the resident was anxious and wanted to go home but not considered at risk, and a CNA reporting no observed wandering, while the DON confirmed that the original elopement evaluation entry was incorrect and that the assessment was actually completed after the incident, resulting in a medical record that did not accurately reflect the resident’s status and care as required by facility policy.
A resident admitted on an antipsychotic (olanzapine 2.5 mg daily) with moderate cognitive impairment and no documented behavioral symptoms had the medication discontinued, as reflected on the MAR, but the discontinuation and rationale were not accurately documented in provider progress notes. A PA’s psychiatric note stated no medication changes were made and did not mention stopping olanzapine, while a telephone discontinue order was entered by an LPN and no further doses were given. Behavioral monitoring tied to the antipsychotic remained active with no recorded behaviors, and subsequent NP notes incorrectly documented that the resident would continue olanzapine, even though it was no longer administered and was not included on discharge prescriptions, resulting in inconsistent and inaccurate clinical documentation.
A resident with dementia, osteomyelitis, multiple DFUs, and a sacral/coccyx pressure ulcer was admitted with complex wound needs, but the facility failed to maintain a complete and accurate medical record for the sacral wound. Although a care plan identified a coccyx pressure ulcer and the wound nurse created handwritten treatment plans involving Santyl, zinc, and sacral dressings, these documents were not incorporated into the EMR and lacked physician orders. Early physician orders addressed wound vac care and foot and heel wounds but omitted the sacral/coccyx ulcer, and wound care notes and late entries referenced refusals and treatments without specifying which wounds were involved or what care was actually provided. The admission MDS documented no pressure ulcers or pressure-ulcer care despite the existing coccyx ulcer care plan, the sacral pressure ulcer diagnosis was not added until later, and TAR documentation for coccyx wound care did not begin until after a delayed physician order was entered, resulting in an incomplete, inconsistent, and non–policy-compliant record of the resident’s sacral pressure ulcer and its treatment.
A resident with multiple psychiatric and pain diagnoses experienced distress and verbal altercations during two roommate changes, including reported threatening and mocking comments, crying, yelling, and behavioral escalation. Staff contacted the ADON and intervened, but did not document the behavioral episodes, roommate conflicts, or change-of-condition monitoring in the clinical record, despite facility policies and staff expectations that such events be charted. In a separate case, another resident with diabetes, chronic pain, cancer, and a stage 4 pressure ulcer was on hospice and had declining oxygen saturation, with hospice staff applying oxygen at 2L via nasal cannula and documenting hypoxia. However, the facility’s EMR lacked timely physician orders for oxygen, did not include a care plan for oxygen therapy until later, had no documented oxygen saturation monitoring for several days, and was missing hospice visit notes and a hospice binder, resulting in an incomplete and inaccurate medical record of the resident’s oxygen use and change in condition.
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