Failure to Accurately Document Resident Discharge and Condition in Medical Record
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.
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 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.
The facility failed to maintain accurate medical records for multiple residents, including one cognitively intact resident whose ordered Modafinil was never received from the pharmacy, yet several nurses documented administering it on the MAR without corresponding controlled-substance tracking. A resident with severe cognitive impairment and hemiplegia had fewer showers than scheduled, while the DON later completed multiple shower sheets in a CNA’s initials and another CNA signed for a shower she did not provide. Another resident had a urinary catheter removed by an outside urologist, but nurses continued to chart catheter care on the TAR and no progress notes or physician orders reflected the catheter removal or discontinuation of catheter care. A resident with chronic bilateral leg wounds had dressings dated several days old despite daily treatment orders, while an LPN admitted charting treatments as done when they were not. A newly admitted resident with dementia and a hip wound had missing documentation for ordered Oxybutynin doses, TED hose use, catheter care, and dressing changes over several days, with the Regional Nurse Consultant confirming the lack of documented completion.
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 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.
Inaccurate and Falsified Clinical Documentation for Medications, Treatments, and Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and documentation for multiple residents, including inaccurate medication administration records, falsified treatment and shower documentation, and lack of integration of external provider orders into the record. For one resident with multiple sclerosis, osteonecrosis, osteoarthritis, fatigue, and PTSD, the physician ordered Modafinil 200 mg twice daily to promote wakefulness. The MAR showed repeated entries that the Modafinil was unavailable on several dates, but also showed it as administered on multiple other dates. A progress note documented that the resident’s medications were not at the facility, the pharmacy did not have the resident in its system, and the provider had to be contacted to enter the resident. Later, the Regional Nurse Consultant confirmed with the pharmacy that the Modafinil was never received by the facility, yet five nurses had documented that they administered it, despite the absence of the medication and any controlled-substance tracking documentation. Another resident with hemiplegia, cognitive communication deficit, reduced mobility, and cerebral infarction had a care plan requiring assistance with ADLs and scheduled showers. The shower schedule showed ten scheduled showers over a defined period, but the medical record reflected only six completed showers. The shower book initially showed an additional shower, but later review revealed multiple shower sheets for additional dates all completed in the same handwriting, with the same CNA initials, and without nurse signatures. The DON admitted to filling out several of these shower sheets herself and initialing them with a CNA’s initials after calling the CNA at home to ask if showers had been given. Another CNA confirmed that she signed a shower sheet for a shower she did not provide, after the DON approached her and suggested she sign based on having only assisted with a transfer to a shower chair. These actions resulted in shower documentation that did not accurately reflect the care actually provided. For a resident with metabolic encephalopathy, BPH, need for assistance with personal care, and cognitive communication deficit, urology notes documented that the resident no longer required a urinary catheter after a successful voiding trial, and the catheter was removed. Despite this, the TAR showed ongoing documentation by multiple nurses that catheter care was provided twice daily after the catheter had been removed. The nursing progress notes contained no record of the urology appointment, catheter removal, or discontinuation of catheter care orders, and the physician orders were not updated to discontinue catheter care until later. The Regional Nurse Consultant confirmed that the urologist’s after-visit summary was not available in the medical record at the time, that catheter care orders were not discontinued when the catheter was removed, and that there were no orders to reinsert the catheter after removal. Another resident with morbid obesity, diabetes, heart failure, and chronic bilateral lower extremity wounds had physician orders for daily wound care to both legs. Observation showed that the dressings on both legs were dated four days prior, even though the orders required daily changes. The TAR, however, showed that treatments were documented as completed on two of those days by an LPN supervisor. In interview, the LPN admitted documenting that the leg treatments were completed when they were not, explaining that workload issues and working multiple halls contributed, and that she typically signed off treatments before doing rounds and did not go back to correct the record when treatments were not done. A newly admitted resident with orthopedic aftercare needs, a recent fall with fracture, pain, dementia, osteoarthritis, hypertension, GERD, and an indwelling urinary catheter had admission orders for bilateral thigh-high TED hose for three weeks, Oxybutynin 5 mg twice daily, daily catheter care, and a daily dressing change to the right hip. Review of the MAR and TAR showed that the evening doses of Oxybutynin on two days were not documented as administered, the TED hose were not documented as on for the first three days, catheter care was not documented for the first three days, and the right hip dressing change was not documented on two consecutive days. The Regional Nurse Consultant verified that these medications and treatments were not documented as completed. Across these residents, the survey findings show multiple instances where documentation did not accurately reflect the care and services actually provided, in violation of the facility’s own policy requiring accurate flagging and documentation when medications or treatments are withheld, refused, unavailable, or not given as scheduled.
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