Deficiency in Accurate Medical Record Documentation for Resident Falls
Summary
The facility failed to ensure that the medical record for a resident accurately represented the resident's actual experience, specifically regarding falls. The resident, who had diagnoses including restlessness, agitation, chronic kidney disease, Alzheimer's disease, and delirium, was at risk for falls. The medical record lacked detailed documentation of a fall that occurred on 08/27/24, including the time, place, and specifics of the fall, as well as any post-fall assessment, monitoring, or investigation. Additionally, there was no documentation of a fall on 09/02/24, despite the resident's son requesting emergency services due to increased pain levels and a long wait for x-rays. Interviews with staff revealed that the resident was found on the floor outside her room on 09/02/24, with complaints of left hip pain and inability to move the leg. It took three staff members to transfer the resident from the floor to her wheelchair and then to her bed. The resident was eventually sent to the hospital upon the son's request, where she was diagnosed with a left femur fracture. The Director of Nursing and Resident Care Coordinator confirmed the absence of progress notes regarding the falls on both 08/27/24 and 09/02/24, indicating a deficiency in maintaining accurate medical records.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with osteoarthritis, morbid obesity, and type II DM at risk for pressure ulcers reported not having an air mattress, while the medical record showed active orders and TAR documentation for both an air mattress and a pressure-redistribution mattress over the same period. On observation, the resident was found on a regular pressure-redistributing mattress only, and an LPN confirmed that no air mattress was in use, revealing conflicting and inaccurate documentation in the medical record regarding ordered support surfaces.
A resident with hypothyroidism had a physician order for daily Synthroid 175 mcg, but the MAR contained no documentation of this medication on multiple specified days, and the medical record lacked any explanation for the missing entries. A regional RN confirmed there was no documentation accounting for the absence of Synthroid documentation, resulting in a cited failure to maintain accurate medical records.
A resident with impaired cognition and complex neurological and ventilator-related diagnoses was discharged to a hospital, but the EMR contained no documentation of the discharge, no alert charting, and no change in condition assessment. Although an MDS Discharge Return Anticipated was completed and the facility’s Admission, Discharge, and Transfer Report showed the hospital discharge, progress notes for the relevant period lacked any information about the reason for discharge or the resident’s condition at the time. The interim DON and ADON confirmed the absence of required documentation, despite a facility policy requiring each medical record to accurately represent the resident’s experience and progress.
A cognitively impaired resident with a court-appointed guardian, identified as at risk for elopement and requiring 24-hour supervision, left facility property and was observed down the street near a public park and later at the end of the facility’s sidewalk near the road, refusing to return inside. Multiple staff, including the DON, SSD, an LPN, and a UM, confirmed the resident had been outside unsupervised and that the DON instructed the LPN not to chart the incident because it was not considered an elopement. Review of the medical record showed no documentation of this event, despite facility policy requiring an incident report and medical record notation when a resident leaves the facility without authorization or necessary supervision.
The facility failed to document meal intakes for a resident with multiple serious diagnoses, including secondary malignant neoplasm of bone, aplastic anemia, multiple myeloma not in remission, need for assistance with personal care, and adult failure to thrive. The resident’s MDS indicated a need for supervision or touching assistance with eating, yet review of the record showed only one documented meal intake during the stay, with no entries for all meals on one day and a missing lunch entry on another day. The Regional DON confirmed the missing documentation, which did not align with the facility’s Food and Nutrition Services policy requiring provision and tracking of meals to meet residents’ nutritional needs and preferences. This issue was discovered incidentally during a complaint investigation.
Surveyors found that the facility failed to maintain complete and accurate medical records for multiple residents. One resident with complex cardiac and renal conditions had a renal diet order discontinued without a new diet order entered into the EMR. Other residents with stroke, atrial fibrillation, metastatic cancer, skin breakdown risk, and heart failure had physician orders and care plans for vital signs every shift, BP checks with antihypertensive administration, pain assessments every shift, low air loss mattress function checks, skin fold care, and heart failure monitoring, yet the MAR showed repeated missing entries for these required assessments and treatments over many shifts. Staff interviews and record reviews confirmed that these omissions were not documented as refusals and were inconsistent with facility policies on change in condition and pain assessment and management.
Inaccurate Medical Record Due to Conflicting Mattress Orders
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and consistent medical record for a resident when documentation contained conflicting information about ordered support surfaces. The resident, admitted with bilateral primary osteoarthritis of the hip, morbid obesity, and type II diabetes mellitus with hyperglycemia, was cognitively intact and identified as at risk for developing pressure ulcers per a recent MDS 3.0 assessment. During an interview, the resident reported not having an air mattress since the end of March 2026, yet physician orders dated 04/16/26 and the April 2026 Treatment Administration Record showed active orders for both an air mattress and a pressure-redistribution mattress from 04/16/26 through 04/19/26, with documentation indicating that both surfaces were in place from 04/16/26 through 04/18/26. An observation on 04/19/26 revealed the resident was on a regular pressure-redistributing mattress and not an air mattress. At the time of this observation, an LPN confirmed that only a pressure-redistributing mattress was in use, despite the presence of two conflicting mattress orders in the medical record. This inconsistency between the resident’s report, the actual mattress in use, and the documented orders and TAR entries demonstrated that the facility did not ensure the accuracy and consistency of the resident’s medical record.
Failure to Maintain Accurate MAR Documentation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical record documentation for one resident. The resident was admitted on 10/15/21 with diagnoses that included hypothyroidism and had a physician’s order for Synthroid 175 mcg orally once daily for this condition. Review of the resident’s Medication Administration Record (MAR) showed that there was no documentation of Synthroid administration on 04/10/26, 04/11/26, 04/14/26, 04/15/26, and 04/16/26. The medical record contained no explanation or documentation indicating why the Synthroid was not documented on those dates. In an interview on 04/22/26 at 8:25 A.M., the Regional Registered Nurse confirmed that there was no documentation in the medical record regarding the missing Synthroid entries on the MAR. This deficiency was identified during an investigation under Complaint Number 2603937 and reflects non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Failure to Accurately Document Resident Discharge and Condition in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate documentation in a resident’s medical record in accordance with its own policy and accepted professional standards. A closed record review for Resident #59, who had diagnoses including traumatic subdural hemorrhage, intracranial abscess and granuloma, and dependence on ventilator status, showed an admission date of 11/21/25 and a discharge date of 02/10/26. The quarterly MDS dated 02/06/26 documented impaired cognition, and a Discharge Return Anticipated MDS was completed on 02/10/26. The facility’s Admission, Discharge, and Transfer Report indicated the resident was discharged to the hospital on that date. However, concurrent review of the progress notes from 02/05/26 through 02/11/26 with the Interim DON and ADON revealed there was no documentation in the EMR regarding the resident’s discharge. During interviews, the Interim DON and ADON, both recently employed at the facility, stated they were unfamiliar with the resident and the circumstances of the discharge. They confirmed there was no alert charting, no change in condition assessment, and no documentation in the medical record explaining the reason for the resident’s discharge, despite the MDS indicating a Discharge Return Anticipated. The ADON stated that a change in condition assessment and alert charting should have been completed if the resident left emergently. In a follow-up interview, the Interim DON reported that the Administrator later explained the resident had a scheduled surgical appointment at the hospital and was discharged from the hospital to another LTC facility, but this information was not reflected in the resident’s medical record. Review of the facility’s “Documentation in the Medical Record” policy, dated 01/02/24, showed the expectation that each medical record present an accurate representation of the resident’s experience and progress through complete and accurate documentation, which was not met in this case.
Failure to Document Resident Elopement in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document in the medical record when a resident left the facility property unsupervised, contrary to facility policy and accepted professional standards for maintaining medical records. The resident had multiple diagnoses including cognitive deficit, cerebral infarction, aphasia, mood disorder, and depression, and had been found legally incompetent with a court-appointed guardian. An MDS assessment showed severely impaired cognition with a BIMS score of 2, and the resident’s care plan and special instructions specified that he required 24-hour care related to cognition, was at risk for elopement, and was not to leave without guardian permission. An elopement risk assessment identified him as at risk and mobile with a device. The resident reported that he went down the hill in front of the facility and down the street without staff present and that he had left the facility grounds on another day as well. Staff interviews confirmed that on an evening in April, the DON observed the resident down the street on the main road near a park approximately 0.6 miles from the facility, and other staff later found him at the end of the facility’s long sidewalk near the road, where he refused to re-enter the building. Multiple staff, including the SSD, LPN, and UM, corroborated that the resident had been outside near the road and that the DON instructed the LPN not to document the incident in the resident’s chart because the DON did not consider it an elopement. Review of the medical record showed no documentation of the resident leaving the facility property on that date, despite the facility’s elopement policy requiring an incident report and appropriate notations in the medical record when a resident leaves the facility.
Failure to Document Meal Intakes for a Resident Requiring Assistance with Eating
Penalty
Summary
The facility failed to ensure complete documentation of meal intakes in the medical record for one resident, resulting in missing records of nutritional intake over most of the resident’s short stay. The resident, admitted with diagnoses including secondary malignant neoplasm of bone, aplastic anemia, multiple myeloma not in remission, need for assistance with personal care, and adult failure to thrive, had an MDS assessment indicating a need for supervision or touching assistance with eating. Review of the medical record showed that from admission on 04/03/26 through discharge on 04/05/26, only one meal intake was documented, for breakfast on 04/05/26. No meal intakes were recorded for breakfast, lunch, or dinner on 04/04/26, and no intake was documented for lunch on 04/05/26. During an interview, the Regional Director of Nursing confirmed the missing meal intake documentation, which was inconsistent with the facility’s policy requiring provision of meals and attention to residents’ nutritional needs and preferences. This deficiency was identified as an incidental finding during the course of a complaint investigation and was based on closed record review, staff interview, and review of the facility’s Food and Nutrition Services policy dated 09/20/17.
Incomplete and Inaccurate Clinical Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and resident-identifiable information in accordance with accepted professional standards for multiple residents. For one resident with congestive heart failure, type 2 diabetes, hypertension, and end-stage renal disease, the medical record showed that the prior renal gluten-free diet order was discontinued and no new or active dietary order was entered. A nutritional assessment and a dietary progress note both documented that this resident had no diet order in the electronic medical record, and the regional RN confirmed that the diet order had been missed when the facility changed the wording of renal diets. Another resident with a history of stroke, hemiplegia, hypertension, psychotic disorder with delusions, atrial fibrillation, and dependence for ADLs had physician orders for vital signs every shift, scheduled diltiazem via gastric tube, and pain assessments every shift. Review of the MAR over two months revealed multiple missing entries for vital signs on various shifts, missing pain assessments on several shifts, and no documentation of blood pressure being taken prior to numerous doses of diltiazem on multiple consecutive days. The regional RN confirmed these documentation gaps. Facility policies on change in condition and pain assessment stated that nurses would monitor residents, notify the medical team of changes, and record information in the medical record, and that pain would be assessed, evaluated, and treated. A third resident with metastatic cancer (pancreatic, liver, spinal), dementia, stroke, repeated falls, heart disease, and constant pain had a care plan for pain related to metastatic cancer and an order to assess pain every shift. MAR review showed repeated absences of pain assessment documentation on multiple day, evening, and night shifts in the weeks before discharge, which the regional RN verified. Another resident with kidney infection, heart disease, gait and mobility abnormalities, malnutrition, and low back pain had orders for a low air loss mattress with placement and function checks every shift, and for skin fold care with antifungal cream three times daily. The MAR showed no documentation of mattress checks for nearly a full month and into the next month, and missing documentation of ordered skin fold care on several shifts, even though observation confirmed the resident was on a low air loss mattress. An LPN stated that air mattress checks were to be documented in the treatment section of the MAR. A fifth resident with respiratory failure, COPD, peripheral vascular disease, arthritis, heart disease, chronic pain, and reduced mobility had a care plan for cardiac impairment and an order to monitor for signs of worsening heart failure. MAR review showed missing documentation of heart failure monitoring on several evening and night shifts over two months, and progress notes did not show that the resident had refused this monitoring. The resident reported no concerns with symptom monitoring or nursing care, but the regional RN confirmed the absence of required documentation. Across these residents, the survey findings showed that ordered assessments, monitoring, treatments, and diet orders were either not entered, not documented, or incompletely documented in the medical record, contrary to facility policies and accepted professional standards.
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